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Zayniddin Norman ugli, candidate of medical sciences, doctoral candidate of the RSSC of them. V. Vakhidova RSCH them. V. Vakhidova of the Ministry of Health of the Republic of Uzbekistan E-mail: zayniddin_norman@mail.ru
TO THE QUESTION OF CLASSIFICATION AND PREVENTION YATROGENIC DAMAGE TO VESSELS
Abstract: Develop a classification of iatrogenic damage to blood vessels and their consequences. Keywords: Uniform classification of iatrogenic damage and its consequences, qualitative and quantitative characteristics of all their variants.
So far, in domestic and foreign literature, studies of iatrogenic vascular pathology are rather few. In this regard, the intensification of research to create a unified classification and the development of adequate preventive measures to reduce the level of iatrogenic vascular damage.
It should be noted that the choice of surgery depends on: the prevalence of the pathological process; localization of as-
Our experience in studying this issue was the basis for
This classification includes the following provisions:
- patients with partial disability after correcting iatro-genic vascular damage, temporarily;
- patients with complete disability due to iatrogenic damage, due to complications such as: ischemic contracture; trophic ulcers; gangrene and amputation of extremities and organ extirpations. At the same time, the types, forms and nature of the means used were taken into account.
Most often, iatrogenic vascular damage occurs during angiographic studies, somewhat less frequently during an-giosurgical and general surgical operations. At the same time, an insignificant percentage in the total amount is: obstetric-gynecological and neurosurgical interventions.
However, about half of the vascular damage occurs due to angiographic and angiosurgical interventions: puncture; cath-eterization; the Ilizarov apparatus; hernia repair; removal of veins; reposition ofbone fragments and insertion of the needles became their cause. These factors, naturally, contributed to an increase in the proportion of interoperative vascular iatrogeny.
Our experience shows that the nature of damage to stabbed and cut wounds of vessels of iatrogenic etiology are common.
Thus, the analysis of iatrogenic damage to the vessels by the anatomical location made it possible to establish the frequent wounding of the vessels in the thigh area. The vessels in the pelvic area and retroperitoneal space were significantly less frequently damaged. The causes of these complications were: lack of knowledge on syntopy of the elements of the neurovascular bundle and the error of surgical tactics on the
sociated lesions of surrounding tissues and others. At the same time, the choice of tactics of surgical treatment has always been active and independent of the time of the occurrence of iatrogenic injury and aneurysm.
Therefore, a waiting position in their treatment is fraught with serious complications, in the form of: thrombosis; rupture of aneurysms, etc.
developing a classification of iatrogenic vascular damage. use of tools for surgical interventions on vessels. At the same time, the following clinical signs are observed: bleeding with and without shock; hematomas of various shapes; thrombosis with complete occlusion of vessels and vascular stenosis with chronic hemodynamic insufficiency.
At the same time, on the vessels there are: false aneu-rysms; fistula and their displaced forms.
It should be noted that the prevalence of thrombosis and hematomas in the clinical picture of iatrogenic vascular damage is mainly due to errors in angiographic studies.
When examining patients with iatrogenic aneurysms, it is not always possible to distinguish the outcome from other vascular lesions. At the same time, local swelling is visible in the area of the damaged limb vessel. In addition, depending on the duration of iatrogenic aneurysms, they can be formed or unformed.
Long-existing aneurysms, especially for large sizes, are clearly visible upon inspection. The skin above the swelling is usually of a normal color, but redness, infiltration or thinning of the skin is sometimes noted. Large, tense aneurysms sometimes cause necrotic changes in the skin.
An indispensable method for examining a patient is palpation. This method revealed a large percentage of patients with aneurysms. The consistency of the aneurysm was tightly elastic or tight. At the same time, an important role is played by thrombosis or calcification. Aneurysm size ranges from 0.5 to 10 cm in diameter. They are round or oval. Pulsation is absent or weak; this is due to the following reasons: fatigue, wall calcification or thrombosis of its cavity. The pulsation of the aneurysm, as a rule, catches systolic tremor over swelling.
The method of auscultation is one of the key in the diagnosis of iatrogenic aneurysms. At the same time, systolic murmur is often heard. Thrombosis of the aneurysmal sac with varying degrees, muffled the systolic murmur until its cessation.
Based on the above, we established the clinical symptoms of diagnosing the formation of vascular aneurysm:
- pain in the aneurysm, in the form of pulsating tumorlike formations in the initial stage. At the same time, the symptoms are observed by: arising compression; ischemia; imbibition surrounding soft tissue and nerve trunks. Along with them, complaints associated with ischemic events were noted with the localization of iatrogenic aneurysm on the extremities. These complaints include: fatigue; intermittent claudication; general weakness, hypersensitivity to cold factors, convulsive phenomena, mainly in the calf muscles.
- ischemic nature, usually appearing at the initial stage as: angiospasm; stenosis and occlusion of the main artery. Pain associated with involvement in the pathological process of the nerve trunk in the form of: damage and compression, which are of varying intensity and shooting at the limb. And also, symptoms in the form of: paresis; paralysis; hoarseness voices, compression of the return vagus. At the same time, the large size of the aneurysm, often worries the patient. Cervical aneurysm according to Horner's symptom associated with damage to the sympathetic nerve trunk. In addition, pressure of the main vein and related disorders of the venous outflow, the distal limb, were observed.
At the same time, there were complaints about the feeling of fullness and strengthening of the venous pattern.
Therefore, a well-assembled history contributes to the correct diagnosis of iatrogenic vascular damage and optimization of the choice of treatment tactics.
As a typical example, we present the following medical history.
Patient H. B., 39 years old, (IB No. 3732) entered by gravity.
Complaints at admission: edema of the lower limb; heaviness and shortness ofbreath on exertion and general weakness.
The patient considers herselfa patient since April 2017. On April 21, 2017, the planned operation "percutaneous microdis-cectomy" was performed for hernia of the lumbar spine. During the operation at the stage of access to the spine, abundant bleeding from the working tools arose (before the discharge from the(RSCN). At this stage, the operation was stopped and the tools were removed. During the day, hemoglobin progressively began to fall. In this connection, 04.22.2017 with suspicion of internal bleeding, the patient was transferred to RSCEME, where diagnostic laparoscopy was performed. During the operation, a retroperitoneal hematoma was detected.
An outpatient patient was examined by MSCT of the abdominal aorta from 05.30.2017: signs of an arteriovenous
fistula between the right common iliac artery and the right common iliac vein were found. With ultrasound of deep veins of the lower extremity: deep veins are passable; Valve apparatus wealthy. On both sides in the lower third of the leg is defined edema.
The general condition at admission is satisfactory, the consciousness is clear, the position is active. Sick plump. The skin is a normal color, except for local status. Musculoskeletal system without deformities. In the lungs vesicular breathing, no wheezing. Heart sounds are rhythmic, clear. HELL 120/90 mm. Hg Art. Heart rate 82 per minute The abdomen is soft, painless. Liver at the edge of the costal arch.
Symptom "tapping" negative. Physiological functions are not violated.
When viewed from the left lower limb is increased in volume compared to the right. Palpation of edema of the lower limb, painless. Pulsation at all identification points is determined. Noise over the main arteries there.
Examinations: hemoglobin-112g/l, leukocytes-5.9, plate-lets-240, tochevina-3.5 mmol/l., Creatinine-49 mmol/l, glu-cose-6.5 mmol/l. The remaining indicators in the normal range. ECG: sinus tachycardia, horizontal position E.O.S. HR-100ud\min. P-copy of organs gr. cells: Lung fields without fresh focal and infiltrative shadows. The heart lies broadly on the dome of the diaphragm, enlarged in diameter.
Aorta protrudes. EchoCG: KDO-139ml., EF-58%. Disturbance of local kinetics was not detected. Immunoenzyme an. blood: HBsAg and HCV neg. (-). Diagnosis: Iatrogenic arteriovenous fistula between the right common iliac artery and the vein on the right.
Patient, 06.27.2017, in a planned manner, performed a laparotomy operation. Produced audit of the retroperitoneal space. Under intubation anesthesia, complete midline laparotomy was performed. The intestine is removed in the wound, to the right. Access to the retroperitoneal space is made.
In the projection of the terminal part of the abdominal aorta and the continuation of the right iliac region (along the iliac vessels) there is a rough systolic jitter. A pronounced adhesions process and periprocess in the area of the terminal part of the abdominal aorta and the right iliac region were found. Inflamed and thinned walls of dilated and convoluted venous collaterals are noted, with contact with which bleeding is noted. All the above forms a pulsating conglomerate with systolic tremor. The right ureter is intimately soldered to the back of the conglomerate, which is impossible to mobilize and push back from the inflamed conglomerate.
Selected abdominal aorta below the renal arteries, outside the zone of inflammation. With a trial clamping of the abdominal aorta, systolic tremor disappears. Further, the attempt to extract the acute and blunt by the iliac arteries (OPA,
NPA and VPA) from the inflammatory conglomerate was not crowned with success. The pulsation on the iliac arteries on the right is very weak and practically can not be felt in the conglomerate. This is due to arteriovenous discharge of arterial blood into the venous system through OPV. Differentiate anatomical structures (abdominal aorta, inferior vena cava, iliac arteries and veins) in the scar and inflamed tissues with relatively "disturbed" anatomy was not technically possible. The progress of the operation and the intraoperative picture were reported by telephone to the director of the center, Academician F. G. Nazirov. Given the high risk of intraoperative bleeding and the technical impossibility of mobilizing anatomical structures, it is recommended that the operation be completed with a revision of the retroperitoneal space. Made a reorganization of the abdominal cavity. Hemostasis. A suture was made on the posterior leaflet of the parietal peritoneum, layer-by-layer suturing of the wounds of the anterior abdominal wall. Aseptic dressing.
In the postoperative period, the patient received antibacterial, anti-inflammatory therapy.
After surgery: hemoglobin-120 g, hematocrit-38%, ESR-6 mm, Urea-3.3 mmol, Creatinine-40 mmol, Glucose-6.1 mmol, PTI-88 mg%. In the postoperative period, wounds heal by pri-
mary intention. The patient is discharged for further observation by the surgeon and cardiologist at the place of residence.
Recommended: Endovascular interventions (installation of Endocraft).
In order to prevent iatrogenic vascular damage, it is necessary, when upgrading the qualifications of doctors, to pay great attention to the training of features and the main method of providing emergency care to such patients. In addition to the uniform classification of iatrogenic vascular damage, the frequency of damage to the following vessels should be taken into account:
1. Facial artery and vein. 2. Temporal artery and vein. 3. Posterior artery and vein 4. Common carotid artery. 5. The external carotid artery. 6. Vertebral artery. External jugular vein. 8. Internal jugular vein. 9. Subclavian artery and vein. Axillary artery and vein. Aorta. 12. Superior vena cava. 13. The pulmonary artery and vein. Intrathoracic artery and vein. Unpaired vein. Semi-unpaired vein. Celiac trunk. 18. Hepatic artery. 19. The common artery and vein. 20. External iliac artery and vein. 21. Internal iliac artery and vein. 22. Common femoral artery and vein. 23. Deep femoral artery and vein. 24. Superficial femoral artery and vein. 25. Popliteal artery and vein. 26. Anterior tibial artery. 27. The posterior tibial artery. 2. Taz.
Table 1.
I. Depending II. Depending III. Depend- IV. By anatomical V. By the clinical VI. For VII. By YIII. Okhod:
on the type of on the nature ing on the date location: picture: complica- the nature
intervention: of the form of of occurrence: tions in the of the
funds: vessels: damage:
Endovascular Puncture. Acute (occur- Head. Bleeding with shock. False aneu- Stabbed. Remediation.
Angiographic. Injection. ring at the time The neck. Bleeding without rysms. Cutted. Partial loss
Angiosurgical. Sounding. of medical Subclavian area. shock condition. Arteriove- Tom. of ability to
General surgi- Catheterization. intervention). Anterior mediasti- Hematomas of various nous fistula. work.
cal. Plastic vessels. Remote (aris- num. forms. Pulsating Complete dis-
Traumatic. Autovenous ing after some Posterior mediasti- Thrombosis with hematomas ability.
Oncological. shunting. time after medi- num. complete occlusion of Mixed clini- Death.
Obstetric- gy- Prosthetics. cal interven- Abdominal cavity. vessels. cal forms.
necological. Ligation of ves- tion). Frontal space. Stenosis of the vessel
Neurosurgical. sels. Crotch. with chronic hemody-
Therapeutic. Paravasal manipu- Leverage. namic insufficiency
Oftolmalag- lations. Local area.
icheskie. Removal of ves- Forearm.
Otoloringo- sels. Brush.
logical. Removal of the Inguinal area.
organ. Femoral triangle.
Venesection. Thigh.
The overlay of the Shin area.
Ilizarov apparatus. Shin.
The imposition Stop.
of the needle and Taz.
pin.
Methods for the treatment of iatrogenic vascular damage:
1. Side seam. 2. Circular seam. 3. Autogenous plastics. 4. Au-tovenous shunting. 5. Prosthetics. 6. Skeletization. 7. Throm-bectomy. 8. Dressing. 9. Anti-aogul treatment. 10. Anti-shock therapy. 11. Disintegration of blood substitute. 12. The expansion of the fistula. 13. Elimination of aneurysm. 14. Amputation. 15. Detoxication therapy 16. Regional perfusion. 17. Hyperbaric oxygen therapy. 18. Providing specialized surgical care. 19. Rentgenendovascular complete occlusion of vessels.
Full recovery and temporary disability after successful correction of iatrogenic vascular damage, respectively, should be attributed to favorable and encouraging results.
Necessary measures to eliminate the occurrence of iatrogenic damage should be considered tamponade or finger pressing of the vessel, the maximum reduction in time to provide specialized assistance and timeliness of the latter. High efficacy of reconstructive surgery for iatrogenic aneurysm and fistulas using endovascular complete occlusion of the vessels. At the same time, we often applied it to remote locations of iatrogenic aneurysms and fistulas.
To date, there is no consensus on iatrogenic vascular injuries and there is no uniform classification. Given the urgency of this problem, we attempted to develop this group of vascular damage. The classification is based on a number of clinical, etiological, anatomical and topographical criteria. Our proposed classification of iatrogenic vascular damage is
based on a thorough study of domestic and foreign data on this issue, as well as our many years of observation of patients with traumatic vascular damage.
It must be emphasized that the development of a unified classification of iatrogenic vascular damage is a pressing issue. At the same time, clinical symptoms and outcome have their own characteristics. Depending on various criteria, we have proposed the following classification:
Creating a single form of documentation for classification, treatment and prevention measures is, in our opinion, a priority task that requires urgent solutions.
Findings
1. A single classification of iatrogenic vascular damage should contain the main qualitative and quantitative characteristics in all their variants.
2. The main causes of vascular damage are insufficient knowledge of the topography of tissues in the operated area, errors in the operative technique and the use of general surgical instruments during vessel manipulation.
3. Early diagnosis and qualified assistance is the main direction in reducing the level of complications caused by various interventions on the vessels.
4. Conducting thematic seminars with: students of the institutes of advanced training of doctors, senior students of medical universities in anatomy and emergency vascular surgery, which is an effective measure for the prevention of iatrogenic vascular damage.
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