CC BY
31
DOI: http://dx.doi.org/10.20534/ESR-17-1.2-58-64
Zayniddin Norman ugli, c. m.s., postgraduate student, Yakkasaray Medical Corporation of CMC Polyclinic and In-Patient Hospital Department
of the Vascular Surgery, acad. V. Vakhidov Republican Specialized Center of Surgery.
The Republic of Uzbekistan E-mail: z-norman@inbox.uz Bakhriddinov F.Sh., professor, Head of the Department of Vascular Surgery, acad. V. Vakhidov Republican Specialized Center of Surgery
The Republic of Uzbekistan
Optimization of the surgical tactics in difficult localizations of vascular injury consequences
Abstract: The study of problem shows that for today such aspects as clinical picture, diagnosis, methods of surgical treatment and their consequences in the difficult localization of vascular injuries (aneurisms and fistulas) have been studied insufficiently well. We performed 45 surgeries in patients with TAA and TAVF. Of them 28 (62,2%) patients with TAA; 17 (37,7%) patients with TAVF. Before their admission to our center they were performed primary surgical debridement (PSD) of the wounds in the regional hospitals. The examination of the patients showed that there was not kept up alertness in relation to injuries of the main vessels; activity of surgical tactics in treatment of bleedings; in performance of more careful revision of the wound canal in order to achieve complete hemostasis.
In each concrete case the tactics of surgical treatment depends on, first of all, the accuracy of preoperative diagnosis including data of angiography, multispiral computed tomography (MSCT). On the basis of data obtained there was reliably revealed localization of fistulas and aneurisms, their types, forms, anatomic and technical conditions for carrying out various kinds of vessel reconstructions. The surgeon need in improvement of the knowledge and experience of liquidation of complex difficult for access of the injuries of vessels as well as special learning for performance of surgical restoration or reconstruction of the vascular injury consequences. The purpose of this article is diagnosis and optimization of the surgical treatment of TAA, TAVF in difficult to access localization.
Keywords: vascular injury, traumatic arterial aneurysm (TTA), traumatic arterio-venous fistula (TAVF), difficult localization, diagnosis, surgery.
Introduction
Recent years are characterized by a sharp increase in the number of injuries involving damage of the main vessels. Surgical treatment of traumatic vascular injuries and their effects has a long history. Despite this, some questions are still not solved and require further elaboration. Diagnosis and surgical treatment of traumatic vascular injuries is an actual problem of modern angiosurgery. This is confirmed by studies of this problem a number of domestic and foreign scientists, which underline the feasibility of further development of technologies of diagnostics and principles of optimization of surgical treatment of traumatic vascular lesions [3; 4; 6; 7; 8; 9; 10; 11]. In such injuries mortality reaches up to 15.4-25.5%, and primary amputation is performed to 17.3% of patients, after reconstructive operations from 9.6 to 12.2% [2; 5]. If the damage of large arterial and venous vessels mortality is 10-56%. According to the Korole-va M. P. and others the mortality rate is 25.3% (2011). The wound of the great vessels of the neck is among the severe kinds of injuries. To date, their complications remains complex and poorly solved problem in terms of diagnosis and treatment. In this regard, the unsatisfactory results of treatment, reaching up to 27-75%. For injuries of the neck injuries ofthe vessels occur in approximately 25% of cases. Most patients go to the district hospital where surgery is 63.1% of
them, to specialized departments of vascular surgery reaches only 6.1% of the victims. In this regard, there is a large number of organizational, diagnostic, tactical and technical errors that in some situations leads to disability and even death of patients.
It is pertinent to note that late diagnosis and improper surgical treatment of traumatic vascular injuries lead to death or development of severe complications, ending with a disabilities [1; 7]. In the last decades in Uzbekistan and in the world has increased the demands on the diagnosis and surgical treatment of vascular injuries and their consequences. In this regard, before the health care system and its specialized research centers tasked with developing effective methods of diagnosis and optimization of methods of surgical treatment of traumatic damages vessels.
The analysis of practical materials for the studied problem shows that to date insufficiently studied: clinic, diagnostics, methods of surgical treatment and their consequences, in remote localizations of vascular damage (aneurysmal and fistulas).
Material and methods
In the clinic under our supervision there were 48 patients regarding traumatic arterial aneurysmal (TAA) and traumatic arteriovenous fistulas (TAVF), with hard-to-reach localization. Causes TAA and TAVF are presented in table 1.
In most cases, TAA was observed in men of active working age from 15 to 40 years.
In table 3, we present the distribution of the patients with TAA and TAVF, depending on localization and defeat of arteries.
Table 1. - The causes of TAA and TAVF
№ Causes of TAA and TAVF All patients %
1. Piercing-cutting weapons 24 50%
2. Gunshot wounds (bullet, shot) 5 10,4%
3. Car accident 2 4,1%
4 Blunt trauma 5 10,4%
5 Iatrogenic injury 5 10,4%
6 Other 7 14,5%
Total: 48 100,0
Analysis of patients with TAA and TAVF by age and sex (men - 40 (85,1%), women - 7 (14,8%)) are presented in table 2.
Table 2. - Distribution of patients according to sex and age
Age of the patients Including Quantity of patients%
Men Women
Till 15 years 6 3 9 (18,7%)
16-20 years 4 - 4 (8,3%)
21-30 years 12 1 13 (27%)
31-40 years 9 - 9 (18,7%)
41-50 years 4 3 7 (l4,5%)
51 years or more 6 - 6 (l2,5%)
Total: 41 (85,4%) 7 (14,5%) 48(100%)
Table 3. - Localization TAA and TAVF
Body parts Localization TAA Localization TAVF Quantity of patients%
Neck and head Carotid artery - 2 Spinal artery - 1 4 7 (14,5%)
Trunk Subclavian artery - 8 8 (16,6%)
Lower limb Femoral artery - 17 Popliteal artery - 3 9 4 26 (54,1%) 7 (14,5%)
Total: 31 (65,9%) 17 (34%) 48 (100%)
We present the distribution of the patients with TAA and TAVF, depending on localization and defeat of arteries.
The most frequent localization TAA and TAVF was observed in the femoral artery and 26 (54,1%); subclavian artery — 8 (16,6%); popliteal artery — 7 (14,5 percent).
Local pain observed in the field TAA and TAVF, i. e. the pulsating
In the diagnosis of these pathologies, we drew attention to the presence of: tumours of education and its dimensions, systolic murmur and shake over the affected area. In this case, is made of: body sphygmography, 5 patients with a sharp decrease in the amplitude of the foot and lower third of the leg; angiography — 15 patients, the size of education ranged from 2x2. 5 to 3x3,5 cm; ultrasound 21 patients, education of sizes 1,1x1,6 cm to 6,4x3,2 cm; Doppler — 8; MSCT study — 4 patients: with the right ILCD 0.8 to 1.4, to the left of 1.1 to 1.5 (0.9 to 1.2 normal).
swelling — 35 (74.4%). Severe pain in the formation of TAA and TAVF, that observed due to ischemia, compression and imbibition blood to neighboring tissues, including nerves. These pains subside or may pass with reduced edema, hemorrhagic infiltration and resorption ofthe organization ofthe walls TAA and TAVF. On duration ofexistence, terms traumatic aneurysms and TAVF are presented in table 4.
Results and discussion
The surgical method remains to the main things, in treatment traumatic arteriovenous fistulas and aneurysms. Currently there are proposed many methods of correction this pathology. However, surgical treatment remains one of the most effective method in surgery oftrau-matic arteriovenous fistulas and aneurysms. Difficulties in treatment are associated with complex post-traumatic formations aneurismal and formation ofrough scars in the neurovascular bundle region. Term and character of operations in TAA and TAVF are presented in table 5.
Table 4. -Duration of traumatic arterial aneurysms and TAVF
Duration of TAA and TAVF Quantity of patients Operated
Till 5 months 35 34
Till 1 year 3 2
2-3 years 2 2
4-5 years 5 5
6-9 years - -
10 years or more 3 2
Total: 48 45
Table 5. - Term and character of operations at TAA and TAVF
Duration of TAA and TAVF Ligature Extratopi-cal bypass grafting Side seam Circular seam Autovenous bypass grafting Pros-thetics Patch Total
Till 5 months 13 1 7 4 7 2 1 34
Till 1 year 1 2 3
2-3 years 1 1 2
4-5 years 1 1 2
6-9 years
10 years or more 2 1 3
Total: 15 (33,3%) 1 (2,2%) 11 (24,4%) 6 (13,3%) 7 (15,5%) 2 (4,4%) 3 (6,6%) 45 (100%)
All ofus produced 45 surgeries for patients with TAA and TAVF. Of them: there were 28 (62,2%) patients with TAA, and 17 (37,7%) patients with TAVF. Before admission to our regional hospitals, patients made primary surgical treatment (PST) wound. Is not complied with increased vigilance in respect of injuries of the great vessels, the activity of the surgical treatment of bleeding manifested not carried out a more thorough audit of the wound channel, to achieve complete hemostasis. In each case surgical treatment depends primarily on the accuracy ofpreoperative diagnosis, including angiography, multislice computed tomography (MSCT). Based on the obtained data, reliably learned the localization of the fistulas and aneurysms, their types, forms, anatomical and technical conditions for the possibility of performing different kind of reconstruction of the vessels.
Ligature surgery of the arteries was performed on 15 patients, including subclavian — 4; femoral — 6; popliteal — 1; carotid — 3; spinal — 1. At the same time, were taken into account: the results of MSCT; aneurysmal widening of the artery; when severe tortuosity length from 2.5 to 4 cm, carried out the resection of an aneurysm of the artery and its distal bandaged and stitched. For example, in one case intraoperatively common femoral artery (CFA) cover formation, stony density to 3cm, coming from the mouth of the deep femoral artery of the thigh in the form of the coupling, up to 1 cm within. Opened a cavity about the thrombosed aneurysm, right femoral artery and produced by ligation of the femoral artery and vein. In another case of abscess of denture and arrosive bleeding, rupture of the back wall of the aneurysm in the retroperitoneal space produced by the removal of the prosthesis and tied with VCI and CFA. In difficult scarring processes the arteries were not allocated, performed
ligation of the external carotid artery (ECA). 2 patients had AVF: 1 — fistula between the ICA and the IYV defect vein 0,4x0,7 cm, in which blood loss was 1 liter; 1 patient pronounced scar between the external carotid artery and internal jugular vein (IJV) it was decided to produce ligation of IJV. Bleeding from vertebral artery injuries are frequently observed from the vertebral artery between the third and fourth vertebrae. In such situations, the wound hole under pressure introduced wax mixture with a hemostatic sponge. Bleeding from the vertebral artery is stopped by suturing. Further, to strengthen the aneurysm, a second layer of sternocleidomastoid muscle to flash to the spinal muscles. Given the retrograde pulsation posterior tibial artery (PTA) and good ripple anterior tibial artery (ATA), PTA bandaged. In 1 patient the defect in the wall of the subclavian artery massive adhesions and there was intensive arterial bleeding from the subclavian artery, it was decided to ligate the subclavian artery. In 1 patient with significant difficulties (shifted profusely bleeding) exposed IJV and common carotid artery (CCA) at the base of the skull. In 1 patient, with a defect of the anterior wall of the artery with a size of 4 cm, noted the technical difficulties associated with the allocation of the second segment of the subclavian artery expressed adhesions involving the aneurysmal process, the reconstruction of the vessels in this case were unsuitable. In this regard, the arteries with aneurismatic bag was stitched and bandaged. Mouth thyroid and internal mammary artery, stitched and bandaged, too. Despite this, it was noted the pulsation of the aneurysm wall, overhanging the thoracic cavity. After that, the carotid artery is isolated and 3 segments of the subclavian artery, superimposed carotid-subclavian autovenous bypass grafting.
Figure 1. The stab-slash wound in the area of the neck
Side seam imposed in 11 patients. Thus, in 7 patients, lateral suture of the femoral artery, and 2 cases of lateral suture femoral vein, 1 patient, simultaneously imposed lateral suture arteries and veins, traumatic arteriovenous fistula of the size of defect from 0,3x0,2 cm to 3cm long. One else patients was applied the lateral suture on the defect of aortic arch and anonymous vein after fistula isolation.
The use of optimized surgical tactics and therapeutic technique allowed differentiation of the anatomic masses involving into the process and performance of surgery at more qualitative level. On the basis of clinical symptomatology, angiography and MSCT there was made diagnosis: posttraumatic aorta-venous fistula on the left side of neck. The patient was made operation of ABC division between aorta arch and anonymous vein.
Because the fistula located at the level of aortic arch and anonymous vein during operation there were occurred significant technical complexities and danger of profuse bleeding. In this connection the AIK of the common femur artery and vein was connected for reduction of arterial pressure to 70 mm Hg. The heparin 5000 un. was injected. Then sternotomy was performed. During isolation of arch of ascending aorta there was found damage of the anonymous vein and aortic arch where aorta-venous fistula was between them. For fistula isolation there was inserted clamp between the anonymous vein and aortic arch. The side suture was made on the posterior wall between anonymous vein and aortic arch with prolan thread 5/0. ABC of the fistula was connected by double-row suture and was fixed with pericardial and periaortal purse-string suture. (Fig. 1-6).
f *«- \ .
¿U: 'O \ 4 i
Figure 2. Angiography of TAVF on the aortic arch and anonymous vein
Figure 3. MSCT of the aortic
Under control ultrasound investigation there was noted decrease in linear velocity in the aortic arch and absence of systol-ic-diastolic flow. The patient was discharged under satisfactory condition with restoration of active movements in the extremities. During examination the systolic tremor and murmur were absent.
The following cases reports confirm this approach.
Patient K. A. of 30-year-old, Medical History N5657 of 13.09.2016. Complaints: presence of mass on the left side of neck after knife wound.
Objectively: The general state of the patient at admission was satisfactory. The skin and visible mucous integuments were clean, of normal color. The osseous-articular system was without visible
arch and vein in the neck
deformations. Auscultation showed vesicular respiration in the lungs, rale were absent. The heart sounds were clear, rhythmic. AP 120/70 mm Hg on the both hands, pulse 74 beats/min. The abdomen had normal form, participated in respiration, at palpation it was soft, tenderless. Stool and urination were normal.
Locally: At examination there was found mass on the left of neck, sizes 15x3.0 cm, at palpation tender and movable. The skin was not changed above the mass. There was noted asymmetry of the left side of neck. There was also noted vein dilatation in the area of the chest and abdomen. Under palpation there was found tremor.
Pulsation was determined on all marking points. The murmur were absent under main arteries.
Examination: WBC-6,6±10,9/L. Neu 46,7%; Lym 38,9%, Mon 12,8%; Eos 1,1%; Bas 0,5%; RBC -5,3±10,12/L; HGB — 164 g/l; HCT 49,3; MCV 92,9 L; MCH 30,9 Pg; MCHC 333 g/l; RDW-CV 11,6%; RDW-SD 41,4 L; PLT 237±10,9/L; MPV 8,9 fL; PDW 16; PCT 0,21%. General Urine Analysis — protein — neg., epith. — 0-0-1/%. Leucocytes0-0-1/%.
Biochemical Blood Analysis: Glucose — 5,1 mmol/l.; Urea-4,3 mmol/l; Creatinine 66 umol/l; Na+ (sodium) 142; K+4,7 (potassium); Total protein 78 g/l.; AST 25u/l; ALT 37 u/l; Total bili.
18 umol/l; Conj.bili. 0. Ht — 44%. PTI 72%. HbsAg — neg. Anti HCV (hepatitis -C) — neg.
Roentgenoscopy: Lung fields were without free focal and infiltrative shadows. The roots were cord. Sinuses are free. The heart was lying broadly on the cupula of diaphragm, enlarged in diameter. The aorta was sclerosal unrolled, protruded. ECG: sinus rhythm, heart rate — 90. LVH. Metabolic changes in the myocardium. EchoCG EDV 186 ml, ESV 131 ml, SV 115 ma, output fraction 62%.
Figure 6. Isolation of fistula between aortic arch and anonymous vein and application of the lateral suture on the defect of aortic arch and anonymous vein
Under the local anesthesia into the femur arteries bilaterally there were established introducers 6F. There was performed roent-geneno-vascular temporary complete balloon occlusion of the arterial vessels. There was used balloon catheter of sizes 6x60 mm; For dilatation to the complete occlusion and vessels patency. Occlusion occurred at pressure in the balloon to 9 atm in RBP 10 atm. Contrast Yunigeksol-350-100 ml (1 bottle per 100ml). There were injected 3 thous. MED heparin (Fig.7).
Circular seam superimposed 6 patients, including 2 patients superficial femoral artery (SFA). 1 patient simultaneously produced: a circular seam and lumbar sympathectomy, catheterization of the
epigastric artery to the left, when beginning suppuration of the toes. 2 patients superimposed circular seam of the femoral artery and the lateral suture of the femoral vein. The defect of the femoral artery was 1 to 2 cm in 1 patient, superimposed circular seam of the popliteal artery. In case of big defects (3x1, 2x2 cm) arising in the course of operations performed in 3 patients patch from autovein, 1 patient was performed simultaneously patch the femoral artery and vein, 1 with defect (1,0x0,5 cm), patch the femoral artery, 1 case of inflammation of the walls (defect up to 1 cm) of the artery, it was impossible to select it, had to patch the popliteal artery.
Figure 7. Endovascular temporary total occlusion of the vessels
7 patients underwent autovenous bypass grafting. In marked infiltration of the tissues in the region of aneurysms and arrosive bleeding, 3 patients produced femoral-popliteal autovenous bypass grafting. 1 patient with a defect of the anterior and posterior walls of the femoral artery size from 1.5 to 2 cm at the same time imposed autovenous patch. The start of blood flow preserved systolic trembling on the femoral vein. In this regard, made autovenous bypass grafting. 1 patient superimposed atypical femoral-popliteal bypass. In 1 patient with a defect of the artery, with TAVF up to 2 cm, made autovenous bypass of the right femoral artery and femoral vein patch. In aneurysmal sack dimensions up to 6x6 cm, with thick infiltrated walls, made common femoral-deep femoral autovenous bypass grafting. In 1 patient with a large defect in the wall of the common femoral artery superimposed autovenous bypass surgery of the common femoral artery. Another patient was made resection of SFA and VCI and imposed atypical iliac-femoral allovenous bypass through the muscular lacuna. After 2 months his from the distal anastomosis was observed arrosive bleeding and were bleeding is stopped by suturing iliac-femoral bypass and SFA.
A synthetic prosthesis is made in 2 patients: a defect in the iliac artery up to 4cm, made the prosthetics of the common iliac arteries, by prosthesis 10 mm (B. Braun). When the festering wound in the middle third of the thigh and arrosive bleeding with hemorrhagic shock of the second degree, also with a defect of the femoral artery to 3 cm, were produced atypical iliac-superficial femoral arterial prosthesis.
In our study, 6 patients at the same time, the observed aneurysms and arteriovenous fistulae. For certain categories of patients, was carried out high-tech hybrid operation. Previously, when choosing access and tactics of surgical treatment of the aneurysm subclavian artery, was necessary to break the clavicle. Currently, use hybrid technology. In particular endovascular temporary total occlusion of the vessels and endoprosthesis. Basically, these methods were used in TAA subclavian artery.
In the postoperative period, a complication was observed the following: arrosive bleeding — 3, hemorrhagic shock — 1, festering wounds — 2, limb ischemia — I A grade — 1, hemorrhagic anemia — 1, thrombosis of the popliteal artery — 1.
Conclusions
1. When TAVF and TAA tactics of surgical treatment should be divided into 3 stages: The first stage — full temporary endovascular occlusion of blood vessels. The second stage is the separation arteriovenous fistula angioplasty. Third stage — the elimination and reconstruction of the aneurysm;
2. Temporary occlusion of the vessels of the arterial tributaries is an important point in the treatment of patients with traumatic aneurysms and arteriovenous fistulas. This leads to reducing the volume of operative blood loss, reduced time and duration of operations, as well as tactical and technical errors. All of these techniques and methods positively influence the results of surgical treatment of TAA and TAVF.
References:
1. Bahriddinov F.Sh., Trynkin A. V., Karimov Z. Z., Toirov O. A. Reconstructive surgery of traumatic limb injuries. Proc.: Topical issues of reconstructive and plastic surgery. - T, - 1996. - P. 31-33.
2. Evstifeev L. K. Injury of the main blood vessels. Diss ...Dr. med. Sciences. - M.: - 1995. - P. 240.
3. Korolev M. P., Urakcheev Sh. K., Pastukhov N. K. Surgical treatment of injuries oflarge vessels//Journal of Surgery. - 2011. - No 6. - P. 56-58.
4. Kohan E. P., Metroshin G. E., Batrashov V. A. et al. X-ray vascular stenting of the external iliac artery to remove the post-traumatic arteriovenous fistula//Angiology and vessel surgery. - 2005. - No 5. - P. 49-52.
5. Lemenev V. L. et al., Reconstructive surgery in injuries of the great arteries and veins.//Surgery. - 1998. - No 10. - P. 12-14.
6. Pokrovsky A. V., Shubin A. A., Ktatsevich G. I. et al. Surgical treatment of multiple traumatic arteriovenous fistulas femoral vessels//An-giology and vessels surgery. - 2008. - No 2. - P. 145-154.
7. Samohvalov I. M., Zavrajnov A. A., Kornilov E. A., Margaryan S. A. Surgical tactics in combined gunshot wounds to the limbs injury of major vessels//Journal of Surgery. - 2006. - No 5. - P. 45-49.
8. Samohvalov I. M., Reva V. A., Pronchenko A. A., Petrov A. N. Damage subclavian artery in severe injury of the shoulder girdle and chest//Journal of Surgery. - 2013. - No 1. - P. 45-49.
9. Hamrakulov Z. S. Surgical treatment of patients with traumatic fistula.//Annals of Surgery. - 2002. - No 2. - P. 65-67.
10. Erkut B., Karapolat S., Kavgin M. A., Unlu Y. Surgical treatment of traumatic pseudoaneurysm and arteriovenous fistula due to gunshot injury//Ueus Trauma Acil. Cerrahi Derg. - 2007. - Vol. 13. - No 3. - P. 248-250.
11. Candini R., Ippoliti A., Pampana E.et al. Emergency endograft placement for recurrent aortocaval fistula after conventional AAA re-pair//Ibid. 2002. - No 2. - P. 208-211.
