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13ОРИГИНАЛЬНЫЕ НАУЧНЫЕ ИССЛЕДОВАНИЯ
UDC 617.5-089; 611.134
JAVGONOV U.M., 2ZUGUROV A.KH., 12SULTANOV D.D., JGIYOSIEV I.K., 1TOKHIROV F.S., 1KOSIMOV YU.M.
THE FIRST SUCCESSFUL HYBRID OPERATION IN ACUTE ISCHEMIA OF UPPER LIMB IN TAJIKISTAN
Republican Scientific Center of Cardiovascular Surgery 1Avicenna Tajik State Medical University
The article describes the case of the first successful implementation of a hybrid operation (stenting of the proximal segment of the subclavian artery with open thrombectomy of the brachial artery and arteries of the forearm) with acute ischemia of the left upper limb. In connection with the prolonged course ofsubtotal stenosis of the subclavian artery, total thrombosis of the upper artery and the distal arterial bed of the upper Limbs with the development of acute ischemia. The presence of decompensated diabetes mellitus and acute ischemia refractory to conservative therapy, angioplasty and stenting of the proximal segment of the left subclavian artery with open thrombectomy from the shoulder, ulnar and radial arteries with good results were performed.
Key words: atherosclerosis, subclavian artery occlusion, acute ischemia of the hand, angioplasty, stenting.
:АВГОНОВ У.М., 2ЗУГУРОВ А.Х., ^СУЛТАНОВ Д.Д., :ГИЁСИЕВ И.К., *ТОХИРОВ Ф.С., *КОСИМОВ Ю.М.
ПЕРВАЯ УСПЕШНАЯ ГИБРИДНАЯ ОПЕРАЦИЯ ПРИ ОСТРОЙ ИШЕМИИ ВЕРХНЕЙ КОНЕЧНОСТИ В ТАДЖИКИСТАНЕ
1ГУ «Республиканский научный центр сердечно-сосудистой хирургии» МЗиСЗН РТ 2Таджикский государственный медицинский университет им. Абуали ибн Сино
В статье описывается случай первого успешного выполнения гибридной операции (стентиро-вание проксимального сегмента подключичной артерии с открытой тромбэктомией из плечевой артерии и артерий предплечья) при острой ишемии левой верхней конечности. Наличие деком-пенсированного сахарного диабета и острой ишемии, рефрактерной к консервативной терапии, явилось основными предпосылками к проведению гибридной операции. В отдаленном результате регистрируется хороший результат с полным регрессом ишемии руки.
Ключевые слова: атеросклероз, окклюзия подключичной артерии, острая ишемия руки, ангиопластика, стентирование.
The acute arterial obstruction (AAO) ofthe arteries of the extremities continues to be the most common urgent pathology of the cardiovascular system, which, according to different data, occupies from 43% to 60% of cases in the structure of emergency vascular pathology [1, 2].
Sultanov Dzhavli Davronovich - MD, PhD, professor of Department of Vacular Surgery of the Republican Scientific Center of Cardiovascular Surgery; 734003, Dushanbe city, Sanoi street, 33; mobile: +992918334115; E-mail: sultanov57@mail.ru
The main causes of AAO of the upper extremity are embolism of vessels on the basis of various pathologies of the heart, aneurysms and stratification of the walls of arteries of large caliber [1, 3]. Because of the good development of collateral vessels, the thrombotic process against the background of various types of angiopathy develops far less compared to embolic genesis [3]. One of the other causes of acute ischemia of the upper limb is the thoracic
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outlet syndrome in which extravasal compression of the subclavian artery occurs with the development of its thrombosis or aneurysm followed by embolism of the distal arteries [4, 5].
Despite the development and implementation of the most advanced diagnostic technologies, new methods of operations and medicines, the frequency of amputations with AAO remains at a high level today - 30% [2, 6].
Until the beginning of the twentieth century, traditionally, in the treatment of AAO, open thrombectomy was performed from various types of revascularization operations. The progress of technology has contributed to the emergence of a new trend in medicine - endovascular surgery. According to the recommendations of TASCII for acute limb ischemia, the use of endovascular technology - thrombolysis and aspiration thrombectomy - has better results [7].
At the moment, these operations are considered the gold standard in the treatment of AAO and are widely performed in the daily clinical practice of most major clinics in the world. However, the high cost of such technologies, the need for training highly qualified specialists, the purchase and delivery of disposable consumables are a limiting factor in the spread of «hybrid operations» technology in developing countries, which include our republic in particular [8].
In this regard, we cite the case of the first successful execution of such an operation in acute ischemia of the upper limb in our republic.
Clinical case. Patient S.M., 54 years old, a medical history, entered the clinic on October 17, 2014 with complaints of acute pain, cyanosis, numbness and restriction of movement in the left arm, dizziness, headaches, tinnitus.
From an anamnesis he considers himself sick for the last two days, when he first noticed the appearance and intensification of pain in the left hand and forearm. I was engaged in self-medication, which did not bring much benefit. In this connection, I applied to the polyclinic of the place of residence, where, after examining the doctors, the patient was sent to the Russian Center for Consultation and Treatment.
When viewed, the objective status is without special features. Cyanosis of fingers and hands of the left hand, restriction of movement of fingers is marked. The left hand is cold to the touch, the sensitivity of the fingers and the hand is decreased. Pulsation in the arteries of the left upper limb at all levels is not determined.
According to ultrasound duplex scanning (UDS) of the arteries of the upper extremities, occlusion of the subclavian artery, thrombosis of the brachial, radial and ulnar arteries was detected. In the above arteries, collateral blood flow at a speed of 17 cm/s (Fig. 1).
In the arteries of the superficial palmar arc, the blood flow is collateral, the blood flow velocity is 12 cm/s.
Fig. 1. Duplex scanning of the ulnar artery with Doppler mapping of blood flow. Collateral blood flow is determined at a speed of 17 cm /s.
Based on the clinical data and data from the UDS, the diagnosis is: Acute arterial obstruction of the left upper limb. Acute ischemia of the left arm of lib degree.
In order to more accurately determine the nature of vascular lesions, the patient underwent radiopaque angiography, which revealed occlusion of the proximal segment of the left subclavian artery (Figure 2).
Fig. 2. Radiopaque contrasting aortoangiography of the aorta and branches leaving from its arch. Occlusion of the left subclavian artery is noted
Reocclusion and balloon angioplasty of the left subclavian artery were performed using an Avantgarde balloon, CID diameter 4.5 mm, length 22 mm (Figure 3).
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Fig. 5. Stenting stage of the proximal segment of the left subclavian artery
In control angiography, residual stenosis = 0; Antegrade filling of the subclavian artery is good, the syndrome is not stealing (Figure 6).
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Fig. 3. Radiopaque angiography after reocclusion and angioplasty of the left subclavian artery. There are sites of stenosis with atherosclerotic plaques
In control angiography, areas of stenosis and atherosclerotic plaques in the subclavian artery are noted. Also visualized thrombosis of the bifurcation of the brachial artery and arteries of the forearm (Figure 4).
The mouth of the left subclavian artery is catheterized by the catheter RDC 8 Fr. The conductor 0.014 «is inserted into the distal sections of the subclavian and axillary arteries. In the field of stenosis implanted Stent Hippocampus, Invatec 8.0x18.0 at 14 Atm. pressure (Figure 5).
Fig. 4. Angiography of the arteries of the left upper limb. The occlusion of the distal segment of the brachial artery and the main arteries of the forearm is visualized
Fig. 6. Control angiography of the left subclavian artery. The artery is passable; the subclavian syring syndrome is not visualized
However, the middle and distal segment of the brachial artery and the artery of the forearm are not contrasted (Figure 7, 8).
Fig. 7. Angiography of the left brachial artery. A segment of thrombosis in the distal segment is visible
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Fig. 8. Angiography of the arteries of the forearm. There is no complete contrast
In connection with this, an open thrombectomy was performed from the bifurcation of the brachial artery and the arteries of the forearm. There was a good ante- and retrograde blood flow. On control angiography, all the arteries of the limb are passable, signs of hemodynamic stenosis are not visualized (Fig. 9, 10).
Fig. 9. Control arteriography of the brachial artery. A complete restoration of the patency of the vessel is noted
In the postoperative period, the patient is recommended daily intake of 75 mg Clopidogrel and 2.5 mg Warfarin. The postoperative period proceeded without complications; the patient was discharged in a satisfactory condition on the 3rd day after the operation. Clinical signs of ischemia of the arm completely regressed 6-8 hours later from the operation. Monitoring of patency of the implanted stent and arteries of the arm was carried out with the help of duplex angioscanning.
During follow-up visits and UDS 3 and 6 months after the operation, the patient did not present any complaints, the stent and arterial hand passability was satisfactory at all levels (Fig. 11).
Fig. 10. Control arteriography of the forearm. The passage of the arteries of the forearm is completely restored
Fig. 11. Control duplex scanning of the proximal segment of the subclavian artery in the Doppler mapping of blood flow. The main blood flow into the lumen of the stent is determined
Acute limb ischemia is characterized by a sudden decrease in arterial perfusion of the extremity with the threat of its viability [2, 7]. The results of her treatment depend on the timing of the patient's admission to a specialized clinic, the speed of diagnostic manipulations and the amount of surgery performed [2].
For the primary diagnosis of AAO, duplex scanning is mainly used, more complete information on the states of the distal arterial channel is obtained with the help of various types of angiography [9]. In recent years for the diagnosis of AAO, CT an-giography is being increasingly used, which, being non-invasive, will additionally allow for transverse dissection of the vessel [9].
The goal of surgical treatment of AAO is to restore the patency of the vessel, which is achieved by both endovascular techniques and traditional open surgery.
Comparative evaluation of the effectiveness and frequency of complications of various types of surgical treatment of AAO are given in the table.
Comparative evaluation of the effectiveness and frequency of complications of various types of surgical treatment of AAO
Authors Endovascular treatment Traditional treatment
Number of patients Effectiveness of the operation Death Number of patients Effectiveness of the operation Death
Ouriel L. etal. [10] 57 82 16 57 82 42
TOPAS Investigators [11] 144 82.7 13.3 54 81.1 15.7
The STILE trial [12] 246 88.2 6.5 141 89.4 8.5
As can be seen from the presented performance data table, all surgical methods of treatment have approximately the same efficacy. However, such advantages of the endovascular technique as minimal invasiveness contribute to reducing the risk of various complications and related deaths. Also, when performing catheter thrombolysis with aspiration thrombectomy, minimal contact with the endothelium of the vessel takes place and, consequently, its insignificant damage. However, with the help of open thrombectomy it is impossible to remove blood clots from arteries of small caliber, which is achieved with the help of catheter thrombolysis.
However, there are some limitations in the use of endovascular methods to which the various types of strokes can be transferred within the next 60 days, active bleeding from various organs, intracranial trauma and recent surgery on the brain and pregnancy.
In these cases, traditional surgical interventions are more effective in preventing the development of various life-threatening complications.
Traditionally, after any kind of thrombectomy, when an occlusive-stenotic lesion of the arteries is detected, revascularization is performed by angioplasty, stenting, or shunting operations.
Thus, the interest of this clinical case is that, despite the prolonged course of the occlusal process of the terminal artery, we were able to conduct its recanalization, which, according to the data of K. Linni et al., is impossible in 30% of cases [13]. Despite the presence of distal thrombosis Arteries of the left upper limb and acute ischemia, after the operation, blood circulation was compensated with a distinct pulsation of the distal arterial bed. The choice in favor of stenting of the subclavian artery was due to the presence of decompensated diabetes mellitus, in which open vascularization is accompanied by a high incidence of complications. As the experience of leading clinics of the world and our observation shows, the combination of endovascular and open revascularization of the arteries of the upper limb is an effective, minimally
invasive and promising method of treating acute ischemia, which allows achieving good results in the long-term period.
Авторы заявляют об отсутствии конфликта интересов
LITERATURE
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