I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
SOME ASPECTS OF REGIONAL BLOOD CIRCULATION STIMULATION BY INDIRECT REVASCULARIZATION IN PATIENTS WITH CRITICAL LIMB ISCHEMIA ON THE BACKGROUND OF DISTAL STENO-OCCLUSION OF ARTERIES
МРНТИ 76.29.30
Kosaev J.V., Abushov N.S., Namazov I.L., Babaev N.I.
Scientific Center of Surgery named after M.A. Topchubashev, Baku, Azerbaijan
Abstract
Objective: To study the peculiarities of regional blood circulation stimulation by indirect revascularization in patients with critical limb ischemia (CLI) on the background of distal steno-occlusion of arteries.
Materials and methods: study was carried out in 210 patients with CLI on the background of distal steno-occlusion of arteries. 48 patients conducted standard treatment (control group). Regional blood flow was stimulated in 42 patients with a standard operation of revascularizing osteotrepanation (ROT) (group I), in 51 patients with lumbar sympathectomy (LSE) (group II), in 38 patients - LSE + ROT (group III), in 31 patients - modified with intraosseous laser irradiation (ROT with IOLI) (IV group). The following indicators of arterial and venous blood flow were determined: rheographiy index (RI), linear blood flow velocity (LBV) in the popliteal artery, standing and lying, regional systolic pressure (RSP) standing and lying, regional systolic pressure gradient (RSPG), post-occlusal venous pressure (POVP) standing and lying, the gradient of post-occlusal venous pressure (GPOVD), venous arterial flow index (VAFI) standing and lying. Oxygen saturation of skin (OSS) in the distal part of the foot was also studied. The parameters of regional arterial and venous blood circulation were compared with identical parameters of 48 practically healthy individuals ("reference group").
Results: upon admission to the clinic, patients revealed a sharp violation of the arterial and venous parts of the regional macro- and microhemodynamics. Indirect methods of revascularization, in comparison with the initial data, reliably mobilize regional blood circulation, reduce the degree of chronic ischemia, which is accompanied by an increase in the number of patients with significant and moderate improvement in clinical status. Statistical analysis showed that the mobilization of arterial and venous blood flow reliably depends on the method of stimulation (p <0.05-0.001). In the I and II group of patients, a weak correlation was revealed (r = 0.3), and in the III and IV group of patients, a moderate correlation was found (r = 0.5-0.6). Leveling of RI, LBV and OSS parameters reliably (p <0.05-0.001) depends on the method of blood circulation stimulation with weak (r = 0.3) correlation in group I patients and moderate (r = 0.4-0.6) correlation in II, III, IV groups of patients. These positive results were most pronounced in patients who underwent ROT surgery with IOLI.
Conclusion: stimulation of peripheral blood flow by indirect methods of revascularization is reasonable (p <0.05-0.001 with r = 0.3-0.4-0.5-0.6), if shunt operations in patients with CLI on the background of distal steno-occlusion of arteries is not possible to perform, allowing you to maintain the supporting function of the limb and improve the quality of life.
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ABOUT THEАUTHORS
Kosayev J.V. - Principal scientist of angioiogy department. PhD. E-mail: jvkosayev@mail.ru
Keywords
distal artery occlusion, critical lower limb ischemia, stimulation of regional hemodynamics, indirect revascularization.
Косаев Дж.В., Абушов Н.С., Намазов И.Л., Бабаев Н.И.
Академик М.А. Топчубашев ат. Рылыми хирургия орталь™, Баку, Эзiрбайжан
Ацдатпа
Мацсаты: Артерияныц дисталды стено-окклюзиялы фонында€ы аяктардыц катерлi ишемиясы (А^И) бар наукдстардагы жанама реваскуляризациянын регионарлы канайналым стимуляциясы ерекшелiктерiн зерттеу.
Зерттеу материалдары жане ад/стер/. Артерияныц дисталды стено-окклюзиялык фонында А^И-ы бар 210 наукаска зерттеу щрпзшщ. 48 наукаска стандартты ем (бакылау тобы) щрпзшщ. Регионарлы канайналым стимуляциясы 42 наукаска (РОТ) (I топ) реваскуляризациялык остеотрепанация (РОТ) (I топ), 51 наукаска - бел симпатэк-
АВТОРЛАР ТУРАЛЫ
Косаев Джамаладдин Вахид оглы -
m.f.k., тамыр хирургиясы бел1мшесш1ц Бас Fылыми цызметкер/ E-maii: jvkosayev@maii.ru Жумыс телефоны: +994558911434; ¥ялы телефон: +994502166090
Туйш сездер
артериянын дисталды окклюзи-ясы, аяктардыц Kayinri ишеми-ясы, регионарлы гемодинамика стимуляциясы, жанама реваску-ляризация.
томиясы (БСЭ) (II топ), 38 наукаска - БСЭ+РОТ(Ill топ), 31 наукаска сYЙеккемгшлклaзерлiксэулеленд'румен модификацияланган (СКЛС пен РОТ) (IV топ) стандартты операциясы жасалды. Мынадай артериялык жэне веноздык канайналым кeрсеткiштерi аныкталды: реографиялык индекс (РИ), такым артериясындагы канныц желлкжылдамдь^ы (КЖЖ), турегеп туртандагыжэнежаткдндагырегионарлы систолалыккысым (АСК), регионарлы систолалык кысым градиентi (АСКГ), турегеп тургандагы жэне жатканда€ы постокклюзиялык веноздык кысым (ПОВК), посткокклюзиялык веноздык кысым градиентi (ПОВКГ), турегеп туртандагы жэне жатканда€ы веноздык-артериялык индекс (ВАИ). Сондай-ак табаннындисталды белшдеп терн оттекпен сатурациялау (ТОС) зерттелдi. Регионарлы артериялык жэне веноздык канайналым naрaметрлерi 48 денi сау тулгалардыц («референс тобы») сэйкес naрaметрлерiмен салыстырылды.
Нэтижелер'/: емханага тускен наукастарда регионарлы макро- жэне микрогемодинамиканыц артериялык жэне веноздык бeлiмiнiц курт бузылысы бар екенi аныкталды. Бастапкы деректермен салыстыртанда, реваскуляризациянын жанама эдiстерi регионарлы канайналымды накты мобилизациялайды, созылмалы ишемия дэрежеан тeмендедi, клиникалык мэртебеа бiркaлыnты жэне айтарлыктай жаксар€ан наукастардыц саны артканы байкалды. Статистикалык талдау артериялык жэне веноздык канайналымныц мобилизациясы стимуляция эд^не (р<0,05 -0,001) ткелей байланысты. Наукастардыц I жэне II тобында элаз корреляциялык байланыс (r=0,3), наукастардыц III жэне IV тобында бiркaлыnты корреляциялык байланыс (r=0,5-0,6) аныкталды. РИ, КЖЖ жэне ТОС кeрсеткiштерiн накты нивелирлеу (р<0,05 -0,001) наукастардыц I тобында€ы элаз (r=0,3) корреляциялык жэне наукастардыц II, III, IV тобындагы бiркaлыnты (r=0,4-0,6) корреляциялык канайналым стимуляциясы эд^не байланысты. Осындай оц нэтижелер СКЛС аркылы РОТ операцияларын еткерген наукастарда кеб'рек байкалды.
Туй'н: Артерияныц дисталды стено-окклюзиясы кез1нде АКИ-ы бар наукастарта операция жасау мYмкiн емес болтан жагдайда, eмiр сапасын жаксартатын, аяктардыц лрек кызмелн сактауга кемектеселн (р<0,05-0,001r=0,3-0,4-0,5-0,6) жанама реваскуляризация эдiстерi аркылы перифериялык канайналымныц стимуляциясы непзп эдс болып саналады.
Некоторые аспекты стимуляции регионарного кровообращения непрямой реваскуляризацией у больных критической ишемией нижних конечностей на фоне дистальной стено-окклюзии артерий
ОБ АВТОРАХ
Косаев Джамаладдин Вахид оглы
- к.м.н., Главный науный сотрудник отделени я сосудистой хирургии E-mail: jvkosayev@mail.ru Рабочий телефон: +994558911434; Мобильный телефон: +994502166090
Ключевые слова
дистальная окклюзия артерий, критическая ишемия нижних конечностей, стимуляция регионарной гемодинамики, непрямая реваскуляризация.
Косаев Дж.В., Абушов Н.С., Намазов И.Л., Бабаев Н.И.
Научный Центр Хирургии им. акад.М.А. Топчубашева, Баку, Азербайджан
Аннотация
Цель: Изучить особенности стимуляции регионарного кровообращения непрямой реваскуляризацией у больных с критической ишемией нижних конечностей (КИНК) на фоне дистальной стено-окклюзии артерий.
Материал и методы исследования: исследования проводились у 210 больных больных с КИНК на фоне дистальной стено-окклюзииартерий.У 48 больных проведена стандартное лечение (контрольная группа). Стимуляция регионарного кровотка у42 больных была проведена стандартной операцией реваскуляризирующей остеотрепанации (РОТ) (I группа), у 51 больного -поясничной симпатэктомией (ПСЭ) (II группа), у 38 больных - ПСЭ+РОТ (III группа), у 31 больного - модифицированной с внутрикостномозговым лазерным облучением ( РОТ с ВКЛО)(IV группа).Были определены следующие показатели артериального и венозного кровотока: реогра-фический индекс (РИ), линейная скорость крови (ЛСК) в подколенной артерии, регионарное систолическое давление (РСД) стоя и лёжа, градиент регионарного систолического давления (ГРСД), постокклюзионное 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 кровообращения 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 макро- и микрогемодинамики. Непрямые методы реваскуляризации , в сранении с исходными данными, достоверно мобилизуют регионарное кровообращение, снижает степень хронической ишемии ,что сопровождается увеличением число больных со значительным и умеренным улучшением клинического статуса. Статистический анализ показал, что мобилизация артериалного и венозного кровотока достоверно (р<0,05 -0,001) зависит от метода стимуляции. В I и II группе больных была выявлена слабая корреляционная связь (i=0,3), а в III и IV группе больных - умеренная корреляционная связь (г=0,5-0,6).Нивелирование показателей РИ,ЛСК и СКК достоверно (р<0,05 -0,001) зависить от метода стимуляции кровообращения с слабой( (r=0,3) корреляцией в I группе больных и умереннной (r=0,4-0,6) корреляцией в II, III, IV группах больных. Эти положительные результаты наиболее были выражены у больных, перенесших операцию РОТ с ВКЛО.
Вывод: при невозможности выполнения шунтабельных операций у больных с КИНК при дистальной стено-окклюзии артерий стимуляция периферического кровотока непрямыми методами реваскуляризации является обоснованной (р<0,05-0,001 при r=0,3-0,4-0,5-0,6), позволяющие сохранить опорные функцию конечности с улучшением качества жизни.
Surgical treatment of patients with critical lower limb ischemia (CLI), caused by lesions of the arteries of infrainguinal localization, remains an urgent problem of vascular surgery and angiology, the search for solutions to this issue continues (3.4). Specialists from far and near abroad reconstructive surgery, endovascular interventions and hybrid operations are considered as the main methods of surgical treatment of patients with CLI. However, the results of direct limb revascularization in patients with CLI, due to occlusion of the femoral-popliteal-tibial segment, do not always satisfy surgeons and patients, as it is often complicated by early reocclusion of the reconstructed segment with relapse and exacerbation of critical ischemia (7, 10, 12, 16, 17). These circumstances led vascular surgeons and specialists from other branches of medicine to look for other methods of stimulating peripheral circulation in patients with CLI distal artery damage. In the presence of contraindications for shunt operations for limb preservation, as an alternative to amputation, revascularizing osteotrepanation (ROT) (classic and modified), lumbar sympathectomy (LSE), revascularizing corticotomy, prolonged tunneling are used (6, 7, 9, 11, 15). A differentiated approach to direct and indirect revascularization is recommended (4.8).
To detect circulatory disorders and evaluate the effectiveness of stimulation of peripheral he-modynamics in patients with CLC, especially after indirect revascularization, along with X-ray contrast methods, it is recommended to use non-invasive research methods (1, 2, 11, 13).
Purpose
To study the features of regional blood circulation stimulation by indirect revascularization in patients with CLI on the background of distal steno-occlusion of arteries.
Materials and methods
A prospective controlled clinical trial was conducted. To conduct this study, permission from the Ethics Committee of the Scientific Center for Surgery named after M.A. Topchubashov was obtained. All patients were acquainted with all aspects of surgical treatment before starting treatment and signed the corresponding informed consent before being included in the study.
The study was conducted in 210 patients, aged 28 to 74 years, with critical limb ischemia on the background of distal steno-occlusion of arteries, who were hospitalized at the Department of Vascular Surgery of the National Surgery Center named after M.A. Topchubashov. 146 (69.5%) patients were in active working age. Men - 154 (73.3%),
women - 56 (26.7%). The duration of critical ischemia development ranged from 2 months up to 4 years. In 70 (33.3%) patients, III degree was diagnosed, in 140 patients, IV degree of chronic ischemia. Etiological factors for the development of critical ischemia were atherosclerosis obliterans [142 (67.7%)] and thromboangiitis obliterans [68 (32.4%)]. The reason for the development of critical ischemia was the unreconstructive occlusion of the femoral-popliteal-tibial and tibial-foot segments of the arteries. Among the concomitant diseases, arterial hypertension (145), coronary heart disease (157), chronic cerebrovascular disorder (59%), diabetes mellitus (86), chronic obstructive pulmonary disease (48), gastric ulcer and duodenal ulcer (22), chronic renal failure (22) were revealed.
In 48 patients with CLI, due to the inability to perform direct revascularization in case of patient's refusal or contraindications for indirect revascu-larization, conservative treatment was performed. The following indirect revascularization operations were performed: ROT for 42 patients, LSE for 51 patients, ROT + LSE for 38 patients, ROT with intraosseous laser irradiation (IOLI) in 31 patients. Operations of ROT, ROT with IOLI were performed under epidural or spinal anesthesia, LSE under intubation anesthesia, LSE + ROT under intubation anesthesia + epidural anesthesia.
To establish a diagnosis of CLI and evaluate blood circulation stimulation, clinical and instrumental studies were carried out: determination oxygen saturation of skin (OSS) in the distal part of the foot, rheovasography, ultrasound dopplerog-raphy, ultrasound duplex scanning, and multispiral computed tomographic angiography. Using instrumental research methods, the following arterial and venous blood flow parameters were determined: rheographic index (RI), linear blood flow velocity (LBV) in the popliteal artery, regional systolic pressure (RSP) standing and lying, regional systolic pressure gradient (RSPG), post-occlusive venous pressure (POVP) standing and lying, post-occlusal venous pressure gradient (POVPG), venous arterial flow index (VAFI) standing and lying. The state of regional arterial and venous blood flow was studied upon admission of patients to the clinic and at the end of inpatient treatment. The parameters of regional arterial and venous blood circulation were compared with the identical parameters of 48 practically healthy individuals (the "reference group").
The obtained data were processed with the calculation of the arithmetic mean (X), its average error (sx), correlation coefficient (r) and Pearson's agreement criterion (x2) at a confidence level of P = 0.95 (p <0.05) and an accuracy index (Csx) 6.09.0% (14).
Table 1.
The dynamics of arterial and venous blood flow in patients with CLI on the background of distal steno-occlusion as a result of stimulation of blood circulation by indirect revascularization (X±sx; P=0,95; Csx < 9,1%x.
Results and discussion
Upon admission to the clinic, the general condition of patients was assessed as severe or moderate. All patients had edema of the shin, 140 patients with IV degree of chronic ischemia showed necrotic changes in the soft tissues, necrotic wounds on the fingers, dry gangrene of the fingers or only the distal part of the foot, non-healing foot wound after a previous operation. For pain relief, injections of narcotic analgesics were used, and epidural blockade was performed. After preoperative preparation for 4-5 days, indirect revascularization was performed for patients to stimulate blood flow.
A comparison of clinical results with the control group showed that the number of observations with a significant and moderate improvement in the condition of patients with a decrease in degree of chronic ischemia and transition to mild degree is significantly greater in patients undergoing indirect revascularization operations. In the control group, in 14 patients, despite the standard treatment, due to the aggravation of critical ischemia, small and large amputations were performed, in patients who underwent ROT, LSE, LSE + ROT and ROT with IOLI, such operations were performed respectively in 6, 8, 5 and 2 patients.
The results of the study of regional arterial and venous blood circulation upon admission to the clinic and at the end of inpatient treatment are shown in table No.1. As can be seen from the table, in patients with critical limb ischemia upon admission to the clinic, in comparison with the reference group, there was a sharp violation of almost all indicators of both parts of the blood circulation. Thus, standing RSP decreased by 31.9-33.1% (p <0.05), lying RSP - by 62.7 - 64.4% (p <0.05), lying POVP - by 21.8- 28.7% (p <0.05), POVG standing increased by 25.6 - 26.9% 26.2% (p <0.05), 26.9% (p <0.05), 25, 85 (p <0.05), 26.4% (p <0.05) and 25.6% (p <0.05), VAFI standing - by 84.2 - 89.2% (p <0, 05), VAFI lying - 92.5-109.4% (p <0.05).
Upon admission to the clinic, an increase in RSPG by 79.0 - 90.0% (p <0.05) and POVPG by 60,0 - 76.3% (p <0.05) was observed. It should be noted that the nature and degree of the revealed violations of arterial and venous blood circulation are largely identical with the results obtained in studies of other authors (10). Upon admission to the clinic in patients with CLI of both groups, the value of the RSP standing and lying significantly decreases, but at the same time, the RSPG significantly increases to 1.85-1.86. Simultaneously with the decrease in RSP standing and lying, the lying POVP decreases,
Research groups Reference group n=48 Control group n=48 ROT n=42 LSE n=51 RОТ+LSE n=38 ROT with IOLI n=31
Quantities I II I II I II I II I II
RSP (mmHg) standing 128,3 ±10,5 85,9 ±5,2 92,3 ±5,5 86,2 ±7,1 106,4 ±9,4* 87,3 ±7,1 108,5 ±8,5* 87,4 ±5,8 112,6 ±9,7* 87,6 ±7,0 111,4 ±10,0*
lying 128.3 ±9,9 47,9 ±3,7 52,6 ±4,4 46,4 ±3,2 68,3 ±5,5* 47,6 ±4,1 72,3 ±6,5* 45,9 ±3,4 73,4 ±6,4* 47,3 ±3,9 74,6 ±6,7*
POVP (mmHg) standing 53,8 ±4,4 67,9 ±5,6 63,5 ±5,3 68,3 ±5,5 57,0 ±3,6* 67,7 ±4,1 59,3 ±3,6* 68,0 ±5,0 57,6 ±3,9* 67,6 ±4,6 56,4 ±4,2*
lying 27,2 ±2,1 21,2 ±1,7 21,7 ±1,9 20,5 ±1,7 24,0 ±1,4* 19,4 ±1,3 23,3 ±1,5* 20,2 ±1,5 24,6 ±1,8* 21,0 ±1,6 25,6 ±1,6*
VAFI (%) standing 41,9 ±3,1 79,0 ±6,4 68,7 ±5,2 79,2 ±6,4 53,6 ±4,4* 77,5 ±6,3 54,7 ±4,6* 77,8 ±6,1 51,2 ±4,5* 77,2 ±5,9 50,6 ±3,9*
lying 21,2 ±1,7 44,3 ±3,4 41,3 ±4,1 44.2 ±3,2 35,1 ±2,9* 40,8 ±3,4 32,2 ±2,6* 44,0 ±3,7 33,5 ±2,9* 44,4 ±3,5 34,3 ±2,7*
RSPG 1 1,79 ±0,14 1,75 ±0,15 1,86 ±0,15 1,56 ±0,12* 1,83 ±0,14 1,50 ±0,12* 1,90 ±0,15 1,53 ±0,13* 1,85 ±0,16 1,53 ±0,13*
POVPG 1,98 ±0,17 3,20 ±0,27 2,92 ±0,22 3,33 ±0,25 2,38 ±0,18* 3,49 ±0,26 2,66 ±0,22* 3,36 ±0,26 2,34 ±0,20* 3,17 ±0,27 2,30 ±0,20*
Notes: - ROT - revascularizing osteotrepanation; LSE - lumbar sympathectomy; ROT + LSE - - revascu-larizing osteotrepanation + lumbar sympathectomy; ROT with IOLI - revascularizing osteotrepanation with intraosseous laser irradiation; RSP - regional systolic pressure; POVP - post-occlusive venous pressure; VAFI - venous arterial flow index: RSPG - regional systolic pressure gradient; POVPG - postocclusal venous pressure gradient; I - upon admission to the clinic; II - at the end of inpatient treatment - * - the difference between indicators I and II on the horizontal line is statistically significant (p <0.05).
and the standing POVP increases, while the POVPG increases from 1.98 ± to 3.33 ± 0.29. In patients with CLI VAFI increases both standing and lying. We agree with the opinions of other authors that an increase in POVPG, as an increase in resistance in the microvasculature, leads to opening of arterio-venous shunts with a further deterioration in tissue perfusion.
Increased VAFI indicates a decrease in the pressure gradient between the arterial and venous microcirculation, leading to a deterioration in microcirculation. Thus, in accordance with the classification of microcirculatory disorders (1, 2, 11, 13), we revealed a severe degree of microcirculation insufficiency with decompensated hemodynamic disorders and weakening of tissue blood flow.
Along with clinical improvement in general condition, with regression of critical ischemia signs, we observed positive dynamics in arterial and venous regional blood circulation in the control and in the main groups. However, at the end of inpatient treatment in the control group, in comparison with the initial data, we noted slightly unreliable positive dynamics.
In the group of patients undergoing indirect revascularization, by the end of inpatient treatment, a reliable alignment of the regional blood flow parameters was established. Thus, standing RSP increased by 23.4 - 28.8% (p <0.05), lying RSP -
47.5 -59.9% (p <0.05), lying POVP - by 17.1 - 21 9% (p <0.05). Standing POVP decreased by 12.5 -16.6% (p <0.05), standing VAFI by 29.4 - 34.5% (p <0.05), lying VAFI - by 20.6 - 23.9 % (p <0.05). At the end of inpatient treatment, a decrease in RSPG was detected by 16.2 - 19.5% (p <0.05), POVPG -by 23.8 - 30.4% (p <0.05)
Indirect methods of revascularization in patients with CLI led to an increase in RSP standing and lying, in VAFI standing and lying, in RSPG, in POVPG and in POVP lying with a simultaneous decrease in POVP standing. A decrease in VAFI standing and lying indicates an increase in the pressure gradient between the arterial and venous parts of microcirculation, leading to an increase in tissue perfusion.
We performed a statistical analysis of dependence of the regional blood flow stimulation degree (VAFI standing and lying, RSPG, POVPG) on individual methods of indirect revascularization (%2; p; r) (Table 3). It was revealed that VAFI standing and lying, RSPG, POVPG significantly (p <0.05 - 0.001) vary depending on the method of indirect revascularization; between the peripheral circulation stimulation degree and indirect revas-cularization methods, there is mainly a moderate correlation (r = 0.4-0.6). Despite a significant (p <0.05) change in these parameters, in the group of patients who underwent ROT, there is a weak correlation (r = 0.3).
Quantities Research groups Control group n=48 ROT n=42 LSE n=51 ROT+LSE n=38 ROT with IOLI n=31
VAFI standing decreased 18 25 %2=4,355 p<0,05 r=0,3 32 %2=6,304 p<0,05 r=0,4 28 %2=11,162 p<0,001 r=0,5 26 -2=16,414 p<0,001 r=0,6
without change 30 17 19 10 5
VAFI lying decreased 17 25 2=5,230 p <0,05 r=0,3 34 -2=9.668 p <0,01 r=0,4 28 -2=12,451 p <0,001 r=0,5 25 -2=15,474 p <0,001 r=0,6
without change 31 17 17 10 6
R S P G decreased 21 28 -2 =4,473 p <0,05 r = 0,3 33 -2 =4,380 p <0,05 r = 0,3 27 -2 =6,411 p <0,05 r = 0,4 27 -2 =14,844 p <0,001 r = 0,6
without change 27 14 18 11 4
P O V P G decreased 19 26 -2 =4,464 p <0,05 r = 0,3 31 -2 =4,446 p <0,05 r = 0,3 29 2 X =11,604 p <0,001 r = 0,5 26 -2 =15,070 p <0,001 r = 0,6
without change 29 16 20 9 5
Table 3.
The correlation of changes in the parameters of arterial and venous regional blood circulation with regional blood circulation stimulation methods (number of patients, -l ;p;r)
Notes: - ROT - revascularizing osteotrepanation; LSE - lumbar sympathectomy; ROT + LSE - - revascu-larizing osteotrepanation + lumbar sympathectomy; ROT with IOLI - revascularizing osteotrepanation with intraosseous laser irradiation; VAFI - venous arterial flow index; RSPG - regional systolic pressure gradient; POVPG - post-occlusive venous pressure gradient.
Table 2.
Dynamics of RI, LBV and OSS in patients with CLI on the background of distal steno-occlusion as a result of blood circulation stimulation by indirect revascularization (X±sx; P=0,95; Csx < 9,1%%)
Research groups Reference group n=48 Control group n=48 ROT n=42 LSE n=51 ROT+LSE n=38 ROT with IOLI n=31
Quantities I II I II I II I II I II
RI (units) 0,62 ±0,04 0,29 ±0,02 0,30 ±0,02 0,28 ±0,02 0,42 ±0,03* 0,28 ±0,02 0,43 ±0,03* 0,29 ±0,02 0,46 ±0,03* 0,29 ±0,02 0,50 ±0,04*
LBV (cm/ sec) 63,9 ±5,6 37,6 ±3,1 41,3 ±4,0 36,9 ±2,1 47,4 ±3,9 38,2 ±2,9 50,6 ±4,5* 37,3 ±3,1 51,8 ±4,5* 36,8 ±2,8 52,3 ±4,9*
OSS (%) 96,4 ±8,4 52,3 ±4,7 55,2 ±5,0 51,9 ±4,7 62,1 ±4,7* 51,3 ±4,4 62,7 ±5,3* 50,2 ±3,9 63,8 ±5,3* 52,4 ±4,9 68,5 ±5,2*
Notes: - ROT - revascularizing osteotrepanation; LSE - lumbar sympathectomy; ROT+ LSE - revascularizing osteotrepanation + lumbar sympathectomy; ROT with IOLI - revascularizing osteotrepanation with intraosseous laser irradiation; I- upon admission to the clinic; II- at the end of inpatient treatment * - the difference between the indicators I and II on the horizontal line is statistically significant (p <0.05)
To assess the effect of indirect revascularization operations on regional hemodynamics, we also studied the parameters of RI, LBV and OSS (Table 2). As can be seen from the table, upon admission to the clinic in patients, the RI, LBV and OSS parameters, in comparison with the reference group, were characterized by a pronounced decrease in all examined groups. In patients with CLI, a decrease in total blood flow (a decrease in RI), a decrease in tissue perfusion (a decrease in OSS), and an increase in peripheral vascular resistance (a decrease in LBV) were revealed.
At the end of inpatient treatment in the control group, we noted a tendency towards an improvement in RI, LBV and OSS. In the main clinical groups, in comparison with the initial data, an increase in RI was recorded by 50.0 - 72.4% (p <0.05), LBV by 28.5 - 42.15 (p <0.05), and OSS by 19.6 - 30.7% (p <0.05). The indicated dynamics of the parameters allows us to judge the stimulation of total blood flow, a decrease in peripheral
vascular resistance and an increase in the oxygen supply of tissues in the ischemic limb in patients with CLI after indirect revascularization. Comparing the dynamic changes in RI, LBV and OSS between clinical groups, we noted a more pronounced leveling of these parameters in the group of patients who underwent ROT with intraosseous laser irradiation.
We have analyzed the correlation between changes in RI, LBV, OSS and regional blood circulation stimulation methods. To this end, we studied the correlation coefficient (r) and the Pearson agreement criterion (x2) at a confidence level of P = 0.95 (p <0.05). (Table 4) Statistical analysis showed that in the group of patients with mobilization peripheral blood flow was performed by operations of LSE, LSE + ROT and ROT with IOLI, these indicators are significantly (p <0.05-0.001) improved depending on regional blood circulation stimulation method and there is a moderate correlation between them (r = 0.4 - 0, 6). In the group of patients who underwent ROT surgery, depending on
Table 4.
The correlation of changes in the RI, LBV and OSS with regional blood circulation stimulation methods (number of patients,
x2 ;p;r)
Research groups Quantities Control group n=48 ROT n=42 LSE n= 51 ROT+LSE n=38 ROT with IOLI n=31
RI increase 20 27 x2=4,593 p<0,05 r=0,3 36 %2=8,418 p<0,05 r=0,4 28 x2=8,816 p<0,01 r=0,4 27 x2=16,131 p<0,001 r=0,6
without change 28 15 15 10 4
LBV increase 18 26 ^ =5,339 p <0,05 r=0,3 32 x2=6.304 p <0,001 r=0,4 28 x2=11,162 p <0,001 r=0,5 26 x2=16,414 p <0,001 r=0,6
without change 30 16 19 10 5
OSS increase 18 25 x2 =4,355 p <0,05 r = 0,3 33 x2 =7,328 p <0,01 r = 0,4 29 x2 =12,894 p <0,001 r = 0,5 26 x2 =16,414 p <0,001 r = 0,6
without change 30 17 18 9 5
Notes: - ROT - revascularizing osteotrepanation; LSE - lumbar sympathectomy; ROT+ LSE - revascularizing osteotrepanation + lumbar sympathectomy; ROT with IOLI - revascularizing osteotrepanation with intraosseous laser irradiation; RI - reographic index; LBV - linear blood flow velocity; OSS - oxygen saturation of the skin
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА № 2-2020
the blood flow stimulation method with a weak correlation, these indicators are significantly improved. A statistical analysis was carried out between two (classical ROT and ROT with IOLI) clinical groups and it was found that when performing ROT with IOLI, peripheral circulation stimulation was significant (p <0.05) with weak or moderate correlation (r = 0.3-0, 4) (table 4)
Despite the positive dynamics in the regional arterial and venous blood circulation, at the end of inpatient treatment, the quantities of these parameters statistically significant differed from the reference group. Nevertheless, judging by data, in comparison with the control group, patients undergoing indirect revascularization operations showed significant stimulation of regional blood circulation.
A comparative study of the RI, LBV and OSS dynamics showed that the best method of peripheral blood flow stimulation by indirect revascularization
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Findings
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2. If it is impossible to perform shunt operations, the stimulation of peripheral blood circulation by indirect methods of revascularization significantly improves the clinical results of treatment, which makes it possible to recommend such operations as a justified method of complex surgical treatment of patients with CLI as an alternative to amputation.
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