Вопросы диагностики, определения показаний к операции и результаты непрямой реваскуляризации у больных дистальным поражением артерий с критической ишемией нижних конечностей Текст научной статьи по специальности «Клиническая медицина»

I. ДИАГНОСТИКА И ЛЕЧЕНИЕ

МРНТИ 76.29.30

DIAGNOSTIC ISSUES, DETERMINATION OF INDICATIONS TO THE OPERATION AND RESULTS OF INDIRECT REVASCULARIZATION IN PATIENTS WITH DISTAL LESION OF ARTERIES AND CRITICAL LIMB ISCHEMIA

ABOUT THE ÄUTHORS

Sultan Samedovich Manafov-

MD, Professor, Head of the Department of Radiology and Radiation Therapy.

sevilmm@rambler.ru

Kosayev Jamal -

PhD, Senior Researcher of the Department of Vascular Surgery. sevilmm@rambler.ru

Manatov Sultan -

Professor, Head of the Department of Radiology,

Akhverdiyeva Tahira -

Senior Researcher, Doctor of Medical Sciences, Department of Radiology.

Khasayeva Narmina -

Junior Researcher, Department of Radiology.

Keywords

obliterating arterial diseases, critical ischemia of the lower limbs, indirect methods of revascularization

АВТОРЛАР ТУРАЛЫ

Султан Самедулы Манафов -

м.Ед., профессор, рентгенологияжэне сэулелI терапия бел/мшесшц басшысы.

sevilmm@rambler.ru

Косаев Джамал -

философия Fылымдарыныц кандидаты, кан-тамырар хирургиясы кафедрасыныц а¥а Fылыми кызметкер/.

sevilmm@rambler.ru

Манафов Султан -

профессор, сэлулел/ зерттеу бел/мшесшц менгерушС,

Ахвердиева Таира -

а¥а рылыми кызметкер, медицина Fылымдарыныц докторы, сэлулелI зерттеу бел1мшес1

Хасаева Нармина -

сэлулелI зерттеу бел/мшесшц Fылыми

кызметкер).

Тужн сездер

артериялардьщ бггепш (облите-рациялайтын) аурулар, ая^тыц сыни ишемиясы, ткелей емес реваскуляризациялау эдiстерi

Kosaev J.V., Manafov S.S., Akhverdieva T.G., Khasayeva N.R.

Scientific Center of Surgery named after acad. M.A. Topchubashova, Baku, Azerbaijan

Abstract

Aims: to conduct a complex diagnosis; to clarify the indications for methods of indirect revascularization; to study the surgical treatment results of patients with distal lesions of the arteries and CLI. Objects cnd methods of study: 174 patients aged from 23 to 78 years with non-reconstructive occlusions of the distal arteries and CLI were selected for the study; LSE was performed to stimulate regional hemodynamics for the first group (47patients); ROT of the tibia and femur was performed for the second group (43 patients); LSE + ROT were performed for the third group (48 patients); The control group consisted of 36 patients with similar pathology who had conventional conservative therapy. Cliniccl cnd pcaccliniccl [s.a. skin thermometry; determination of skin saturation with oxygen; Doppler ultrasonography and angioscanning with determination of ABPI; regional systolic blood pressure (RSP); rheovasography with rheographic systolic index definition] studies and MSCT angiography were performed in order to determine the diagnosis of CLI, specify indications for a particular technique of indirect revsacularization, and evaluate the results of treatment Resecach results: Research results were rated on the Rutherford R.B scale. The methods of indirect revascularization allowed us to stick to small amputations and, in the majority of patients, to maintain the support functions of the limb and improve the quality of life. At the same time, the best results were obtained with the combined operations of LSE and ROT. It is necessary to clearly define the indications for a particular technique in order to avoid discrediting the methods of indirect revascularization, as an alternative to amputations in case of distal artery occlusion. Correct assessment of the clinical status, regional hemodynamic parameters and MSCT-angiographic semiotics in determining indications for surgery reduces the unsatisfactory results.

Аяктьщ критикалык ишемиясына шалдыккан наукастардыц артерияларын аныктау, ота жасауга керсетюштер1, жэне лкелей емес реваскуляризациялау нэтижелер1

Косаев Дж.В., Манафов С.С., Ахвердиева Т.Г., Хасаева Н.Р.

акад. М.А. Топчубашов атында?ы Хирургия ?ылыми орталы^ы, Баку к,., Эзiрбайжан

Ацдатпа

Максаты: Аяктыц критикальщ ишемиясына шалдыккан аурулардьц артерияларын хирурпиялык емдеу нэтижелерн зерделеу жэне ткелей емес реваскуляризациялау эдстерне кврсетштерн кешенд диапностикалау, аныктау. Материал жэне зерттеу эд'/стер'/. Аяктыц критикалык ишемиясына шалдыккан аурулардыц дистальды артерияларыныц реконструкциялауга келмейтн окклюзиясымен 23 жастан 78 жаска дейнп жас мвлшерiндегi ауруларяа катысты зерттеу -лержYрпiзiлдi. Репионарлыкпемодинамикасын стимуляциялау Yшiн 47ауруында (фШ топ) ПСЭжасалды, 43 ауруында (екШ топ) - Yлкен жЫншк пен ортан жш сYЙектерiнде РОТ' жасажан, 48 ауруында ^шШ топ) - ПСЭ + РОТ жасалтн. Бакылау тобында уксас сырккаттарына шалдыккан 36 ауру Yшiнжалпы кабылда^ан консервативт ем жасашн. Аяктыц критикалык ишемиясына шалдыккан аурулардыц диагнозын аныктау, ткелей емес реваскуляризациялаудыц кандай да болса эдстернц кврсетюштерш аныктау жэне емдеу нэтижелерн баталау Yшiн клиникалык пен параклиникалык (терi термометриясы, оттепмен тернц сатурациясын аныктау, анпиосканерлеуi жэне жаткан, туртан турнде ЛПИ, РСД аныктау, ГРСД, реографиялык индекс-РИ реовазопрафиялауымен], зерттеулер мен МСКТ -анпиопрафия сиякты аталмыш эдiстерiжурпзшпен. Нэтижелер: зерттеу нэтижелерi Rutherford R.B. et.al. баеанасы бойынша баяаланяан. Ткелей емес реваскуляризациялау эдiстерi шатын ампутациялармен шектелупе мYмкiндiк бердi жэне де квптепен ау-руларда аяктарыныц лрек функцияларын сактап калуга жэне де вмiр сYPуiн жаксартуга мYмкiндiк берд. Сонымен, ец жаксы нэтижелер ПСЭ мен РОТ оталарын аралас жасау кезнде алынюн. Артериялардыц дисталды окклюзиясы кезнде ампутациш балама ретнде ткелей емес реваскуляризациялау тэслдерн дискретитациялауды болдырмау Yшiн сол немесе взпе эдЫц кврсетюштерт накты аныктау кажет. Ота жасауга кврсетюштерт аныктау кезнде репионарлык пемодинамика жэне МСКТ-анпиорафиялык семиотикасыныц клиникалык статусын, кврсетюштерш дурыс баталау канататтанарлыксыз нэтижелердi азайтута мYмкiндiк бередi.

Вопросы диагностики, определения показаний к операции и результаты непрямой реваскуляризации у больных дистальным поражением артерий с критической ишемией нижних конечностей

Косаев Дж.В., Манафов С.С., Ахвердиева Т.Г., Хасаева Н.Р.

Научный центр хирургии им. акад. М.А. Топчубашова, г. Баку, Азербайджан

Аннотация

Цель: проведение комплексной диагностики,уточнение показаний к методам непрямой реваскуляризации и изучение результатов хирургического лечения у больных дистальным поражением артерий с КИНК. Материал и методы исследования. Исследования проводились у 174 больных в возрасте от 23 до 78 лет нереконструк-табельными окклюзиями дистальных артерий с КИНК. Для стимуляции регионарной гемодинамики у 47 больных (первая группа) проводилась ПСЭ, у 43 больных(вторая группа) - РОТ больщеберцовой и бедренной кости, у 48 больных(третая группа) - ПСЭ + РОТ. Контрольную группу составили 36 больных с аналогичной патологией, у которых проводилась общепринятая консерватиная терапия. Для установления диагноза КИНК, определения показания к той или иной методике непрямой ревсакуляризации и оценки результатов лечения проводились клинические и параклинические [кожная термометрия, определение сатурации кожи кислородом ультразвуковая допплерография с ангиосканированием и определением ЛПИ, РСД лежа и стоя, ГРСД, реовазография с определением реографического индекса-РИ ] исследования и МСКТ - ангиография. Результаты: результаты исследования оценивались по шкале Rutherford R.B. et.al. Методы непрямой реваскуляризации позволили ограничиться малыми ампутациями и у большинства больных сохранить опорные функции конечности и улучшить качество жизни. При этом, наилучшие результаты получены при сочетанном проведении операций ПСЭ и РОТ. Для исключения дискредитации способов непрямой реваскуляризации, как альтернатива к ампутациям при дистальной окклюзии артерий необходимо четко определить показания к той или иной методике. Правильная оценка клинического статуса, показателей регионарной гемодинамики и МСКТ-ангиографической семиотики при определении показаний к операции позволяет уменшить неудовлетворительные результаты.

ОБ АВТОРАХ

Султан Самедович Манафов д.м.н., профессор, руководитель отделения рентгенологии и лучевой терапии. sevilmm@rambler.ru

Косаев Джамал -

к.м.н., старший научный сотрудник отделения хирургии сосудов. sevilmm@rambler.ru

Манафов Султан -

профессор, заведующий отделением лучевой диагностики,

Ахвердиева Таира -

старший научный сотрудник, д.м.н., отделение лучевой диагностики.

Хасаева Нармина -

младший научный сотрудник, отделение лучевой диагностики.

Ключевые слова

облитерирующие заболевания артерий,критическая ишемия нижних конечностей, непрямые методы реваскуляризации

Actuality

Chronic obliterative arterial diseases of the lower limbs are and still remain an actual problem of modern angiology and vascular surgery. From 3 to 7.5% of the population in Russia is affected by this pathology. (4.8,) Within 5 years after the onset of the first signs of the disease, critical limb ischemia (CLI) develops in 5% of patients (7). CLI is a severe pathology and is characterized by a high level of disability and mortality (15). According to L.A. Bokeria et al. (2) CLI develops in 30-40% of patients with chronic obliterative arterial diseases of the lower limbs. The frequency of CLI, according to TASK II, is 500-1000 cases per 1 million of population per year (13). Only in 50% of patients with KIHC, it is possible to perform revascularization operations, 25% of patients undergo primary amputation of the hip and tibia, and the remaining patients undergo conservative treatment (13). However, the existing methods of conservative therapy are ineffective, since during the first 6 months, 60% of patients undergo a high-level lower-limb amputation (5.9). In 25% of cases, a primary amputation of the lower limb is performed for the patients with CLI without preliminary revascularization (1.13). It was recorded that 20-25% of patients with CLI who undergo hip and tibia amputation die during the first year, and about 70% of patients die within 5 years (11,12).

The methods of conservative and surgical treatment of CLI are improving every year because of

the advances in medical science and technology. According to the national guidelines for the management of patients with lower limb artery diseases (6), performing direct revascularization is the best treatment for CLI. Among direct revascularizing surgical interventions, there are open (autologous and synthetic shunting, endarterectomy); endovascular (balloon angioplasty, stenting, atherectomy, the use of lasers and cutting balloons, high-temperature angioplasty, fibrinolysis, thrombectomy); hybrid (endovascular + open) operations. Nevertheless, the problem of limb preservation and the choice of tactics for treating patients with CLI is still considered as unsolved. The most difficult group consists of patients with atherosclerotic lesions of the popliteal-tibial segment and the lack of adequate outflow pathways. These circumstances preclude the implementation of direct revascularization.

The circumstances that were mentioned above, as well as the presence of severe concomitant pathologies, high surgical anesthetic risk are indications for performing indirect revascularization in CLI. Indirect methods of indirect revascularization include lumbar sympathectomy, arterialization of the venous bed, greater omentun autotransplantation, microvascular autotransplantation of a skin-muscular flap, a compacttomy by means of the Ilizarov technique, resection of the posterior tibial veins with arterio-venous anastomosis ligation, revascularizing osteotrepanation. In clinical practice,

lumbar sympathectomy and revascularizing osteo-trepanation alone and in combination are most often used for the development of collateral circulation and stopping CLI (3,10).

Nowadays, there are no uniquely accepted criteria for diagnostic methods in order to choose one or another method of revascularization, to assess the effectiveness of stopping the CLI. Clinical and instrumental diagnostic methods have drawbacks, since the results of some researchers often disagree with the data of studies of other authors (3.11).

Thus, patients with CLI require a detailed study of macrohemodynamics and microcirculation of the affected limb. Considering the lack of effect after performing indirect revascularization in a certain percentage of patients with CLI, it is necessary to optimize diagnostic methods and clarify the indications for performing one or another method of indirect revascularization in persons with distal lesions of the peripheral vascular bed without adequate outflow paths.

Aims

to conduct a complex diagnosis; to clarify the indications for methods of indirect revasculariza-tion; to study the surgical treatment results of patients with distal lesions of the arteries and CLI.

Material and methods

Studies were conducted in 174 patients aged from 23 to 78 years with non-reconstructive occlusions of the distal arteries with CLI, who were hospitalized at the department of vascular surgery in 2003-2013. All patients were diagnosed with III-IY degree of chronic ischemia according to the Fonteine-Pokrovsky classification. Until 2010, the diagnosis of KIHK and the determination of indications for one or another method of indirect revsacu-larization were carried out mainly on the basis of complaints, anamnesis, clinical examination and paraclinical [s.a. skin thermometry, determination of oxygen saturation of the skin ("Bionet Model: BM5"), Doppler ultrasonography with angiography and determination of ankle-brachial index (ABI), regional systolic pressure (RSP), in the position of lying and standing, gradient regional systolic pressure (GRSP) ("Sonoace Pico "), rheovasography with rheographic systolic index definition] studies. However, because of the lack of logistical support, angiography was performed only in some patients. Since 2010, MSCT angiography is performed at clinic on the tomograph "Somatom Definition AS 64" manufactured by Simens in order to establish the diagnosis and study the state of regional mac-rohemodynamics and collateral circulation, as well

as Minimax-Doppler-K apparatusis used to study the foot micromax circulation.

For the surgical treatment of patients with distal lesions of the arteries and CLI were performed the lumbar sympathectomy (LSE) under the endotracheal anesthesia in the first group (47 patients), the revascularizing osteotrepanation (ROT) of the tibia and femur under the epidural anesthesia in the second group (43 patients), LSE + ROT under the endotracheal and epidural anesthesia in the third group (48 patients). Conventional conservative therapy that had been adopted in the department of vascular surgery was performed in the control group which consisted of 36 patients with similar pathology.

Results and discussion

Complex preoperative preparation was carried out for 3-5 days before the operation, including drug therapy, long-term epidural blockade (LEB) and intravascular laser therapy (HH). LEB and IVLT were continued for 4-5 days in the postoperative period. LEB was performed by catheterization of the epidural space between L3-L4 or L4-L5 with the injection of 2% - 6 ml of lidocaine every 6 hours. IVLT was carried out with the "Mustang2000 +" device (the length of the wave was 0.63 em, the radiation power at the end of the quartz fiber was 5 mW, the exposure time was 30 min).

Complex preoperative preparation led to a decrease in the intensity of pain, static limb edema, normalization of the patient's sleep, subsidence of the inflammatory reaction, warming of the skin (according to thermometry), and restriction of the ne-crotic process on the legs and foot. These data testify to the mobilization of collateral blood flow and microcirculation in the ischemic limb even before the operation of indirect revascularization, which creates favorable conditions for carrying out LSE, revascularizing osteotrepanation on the tibia. Positive dynamics in terms of ABI, an increase in RSI, skin saturation with oxygen during the preoperative preparation period and an increase in these indicators after operations of indirect revascularization also objectively indicated mobilization of collateral blood flow and microcirculation in the affected limb. The increase in microcirculation is also registered by the study of microcirculation on the dorsum of the foot with the ultrasonic medical diagnostic device "Minimax-Doppler-K".

In the control group, the regression of clinical symptoms was very slow, only thing that was detected is the tendency to improve regional blood flow and microcirculation at the level of the leg and foot.

Mark Effectiveness Control group (n= 36) First group (n = 47) Second group (n = 43 ) Third group ( n = 48)

+3 Significant improvement - - - -

+2 Moderate improvement 8(22,2%) 30(63.8%) 26(60,5%) 34(70,8%)

+1 Minimal improvement 12(33,3%) 11(23.4%) 9(20,9%) 9(18,8%)

0 Without changes 4(11,1%) - - -

-1 Minimal deterioration - - - -

-2 Moderate deterioration 7(19,4%) 6(12,8%) 6(13,9%) 5(10,4%)

-3 Significant deterioration 5(13,9%) - 2(4,7%) -

Table 1.

Evaluation of the results of indirect revascularization in the studied groups with CLI

In the first and third groups, the necrotic wounds on the fingers and foot healed, in some cases a small amputation was performed - amputation or exarticulation of the fingers, transmetatarsal amputation of the foot, respectively, in 6 (12.8%) and 5 (10.4%) patients. In the second group, 2 (4.75%) patients underwent a large amputation at the level of the shin, 6 (13.9%) had a small amputation, and in the remaining patients, the necrotic wound healed. In the control group, 5 (13.9%) patients underwent a large amputation at the level of the hip and shin, and 7 (19.4%) underwent a small amputation.

The results of the effectiveness of treatment in the studied groups of patients were evaluated according to the R.B. Rutherford et al. (14) and shown in the table.

In retrospect, we analyzed the dependence of the results of indirect revascularization techniques on clinical status, indicators of instrumental methods of research and MSCT angiography. At the same time, it was clinically revealed that the continuation of swelling and ischemic pain, the absence of regression of the inflammatory and the necrotic process, warming of the skin in the distal part of the affected limb, the absence of positive dynamics in the indicators of skin saturation with oxygen during the preoperative preparation, as well as pronounced changes in soft tissues upon admission of patients to the clinic negatively affect the results of surgical treatment. With baseline values of ABI below 0.32-0.30 units, RSBP lying below 50-40 mm Hg, RSBP standing below 110-90 mm Hg, HRSBP above 2.0-2.5 units, RI below 0.18 -0.20 units we observed a moderate or significant deterioration in the results on the Rutherford RB scale et al., after operations of indirect revascularization.

The insertion of MSCT angiography into clinical practice has improved the diagnosis of obliterating arterial diseases, including in the stage of critical ischemia. A complete picture of the main and collateral circulation of blood, the state of small arteries in the distal part of the limb, made it possible to clearly define the indications for a

particular method of indirect revascularization. Comparing clinical and angiographic data with the results of operations of indirect revascularization, we came to the conclusion that with occlusion of the femoral-poplite-hip region of the arterial segment, with occlusion of all three arteries of the shin on the full length, with profound changes in the soft tissues of the limb (especially in patients with sugar diabetes) indirect revascularization has proven to be ineffective. In varying degrees, improvement after indirect revascularization was observed: with occlusion of the superficial femoral artery with contrasting popliteal artery through the branches of the deep external pudendal artery of the thigh and with steno-occlusion of the tibial arteries; with occlusion of the femoral-popliteal segment with the presence of collateral blood flow in the arteries of the shin; when blood flow is saved in at least one of the arteries of the shin; with multi-stage occlusion of the arteries of the shin with contrasting of individual segments on the middle, lower third of the shin and foot.

Conclusions

1. When determining indications for indirect revascularization operations, it is necessary to take into account the changes in the soft tissues of the distal part of the limb, the degree of impairment of regional hemodynamic parameters (ABI, RSP lying, RSP standing, RSPG) and angiographic semiotics according to MSCT - angiography.

2. Unreasonable indications for one or another method of indirect revascularization lead to discredit and rejection of these operations, although LSE, ROT and LSE + ROT are alternatives to amputation of the limb with non-reconstructive distal artery disease.

3. Indirect revascularization operations that were performed according to clear indications help to preserve the support function of the limb and improve the quality of life in patients with distal steno-occlusion of arteries with CLI.

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