Surgical policy in patients with diffuse arterial lesion of lower extremities

In spite of the achievements of contemporary surgery the rate of unfavoutable outcomes of reconstructive operations is keeping on to be high. Early postoperative complications because of inadequate choice of method for surgical treatment mount to 25%. Classification of the lesions of arteries of lower limbs is developed with due regards to functional and angiographic data. Simultaneous stenotic total lesions of the aorta, iliac, femoral, popliteal and tibial arteries lesions were considered as diffuse ones. The kind of surgical intervention is such lesions was determined according to functional reserve of collateral blood flow of the lower extremity. In such cases reconstructions only of aorto-iliac segment or multilevel reconstruction is possible (two-stage or one-stage reconstruction). The operation of choice was one-stage reconstruction.     

Diagnosis and treatment of the main arteries in the lower extremities of patients with diabetic foot syndrome]

Results of examination and treatment of 209 patients with diabetes mellitus (DM), complicated by purulent-necrotic affection of foot (PNAF), were analyzed. While choosing patients to determine indications for reconstructive operation performance segmentary pressure (SP) on posterior tibial artery on level of her low third was measured, shoulder-scapular index (SSI) and the PNAF stage (according to classification of Wagner) were determined. In 16% of patients with diabetic affection of III-IV stages, SP indexes ranging 9.3-12.0 kPa (70-90 mm Hg), SSI 0.6-0.9 stenosis or occlusion of the lower extremity main arteries, demanding surgical correction to be done, was revealed. Reconstructive operation on vessels was done in 26 patients with restricted stenosis of femoro-popliteal segment, according to ultrasonic Dopplerometry results, passability of the leg arteries, distance of more than 50 metres, which passes patient without painful sensations, value of SP in both arteries of leg ranging 9.3-12.0 kPa (70-90 mm Hg), SSI more than 0.6. Revascularization operation on arteries of lower extremity was successful in 46 (94%) of 49 patients with DM and PNAF.     

Analysis of complications and indices of cumulative preservation of the lower extremities in their chronic critical ischemia after direct, indirect and composite revascularization

Complications and indices of the lower extremities cumulative preservation in conditions of their chronic critical ischemia after doing the direct, indirect and composite revascularization were analyzed. Surgical treatment and postoperative follow-up was performed in 170 patients ageing 25-84 years. The priority role of a. fibularis in a blood supply of the extremity distal segment in obliterating diseases of the lower extremities arteries was established. After the direct revascularization performance there was noted the lowering of the extremities preservation indices during a follow-up period from 96%--in the first month down to 84%--in 24 months, and after composite revascularization--from 96 to 94%. The direct revascularization conduction, using automyelotransplantation, have permitted to secure the extremity in 95.1% of patients, suffering incurable affection of a nonrecontructable affection of the popliteo-crural segment arteries.     

The role of revascularization in the foot salvage in patients suffering diabetes mellitus with occlusion-stenotic lesions of the shin arteries

There were examined 1363 patients suffering diabetes mellitus with trophic ulcer and purulent-necrotic affection of foot. Conservative treatment or operative intervention on the foot were conducted according to indications in 1176 (86.3%) patients, who no needed revascularization. Revascularization was done in 187 (13.7%) patients. Necessity of reconstruction for occlusion-stenotic affection of the shin arteries was established in 125 (66.8%) of them, shunting into the foot arteries was done in 52 (41.6%). High amputation of the limb was performed in 73 (58.4%) of patients in presence of contraindications for the foot revascularization. In 83.5% of patients suffering diabetes mellitus with occlusion-stenotic affection of the shin segment arteries there were two or one passable arteries of foot, fit for shunting operation.     

Contemporary approach to the treatment of complicated diabetic angiopathy of the lower extremities

The experience of treatment of 278 patients with diabetes mellitus, complicated by the lower extremities diabetic angiopathy, was summarized. The authors had proposed the complex of treatment, including combined application of the high- and low-energy laser irradiation and catheterization of the shin arteries branches and the anterior abdominal wall superficial arteries for an adequate introduction of medicinal agents towards the affection focus. Application of the method proposed had promoted the results of treatment improvement, had permitted to proceed with economical amputation of extremity and to escape the reoperations performance.     

Ways of improvement in surgical treatment of purulent-necrotic complications in the diabetic foot syndrome

Results of surgical treatment of 168 patients with diabetes mellitus (DM) in the diabetic foot syndrome (DFS) were analyzed. Expediency of operative intervention was substantiated by pathogenic form of affection, its depth and diffusion, composition of microorganisms in purulent-necrotic focus. Performance of more extensive surgical treatment or distal amputation of foot with consequent closure of vast wound defect using full-layer subcutaneous-cutaneous flap with protracted selective intra-arterial anti-aggregate and antibacterial therapy was indicated in order to preserve the lower extremity supporting function and for prophylaxis of diffusion of purulent-necrotic affection. Application of improved tactics and surgical treatment in patients with DFS have allowed to reduce frequency of the lower extremity high amputation performance from 24 to 8.6%.     

Surgical tactics in combined lesions of the aortic arch and its thoraco-abdominal segments in nonspecific aortoarteritis]

Seventy-one patients with unspecific aortoarteritis and affections of the aortic arch and its thoracoabdominal segment were treated in the period between 1984 and 1989. All the examined patients had different variants of affection of the brachiocephalic arteries, in 57 (80.3%) of them there was a coexistent affection of the thoracoabdominal segment of the aorta, and in 14 (18.7%) coexistent affection of the abdominal aorta and the lower limb arteries. Operations were conducted on 56 (78.8%) patients. Reconstruction of the brachiocephalic arteries was carried out in 12 (21.4%), of the thoracoabdominal segment of the aorta and the renal arteries in 30 (53.6%), and of the abdominal aorta and lower limb arteries in 9 (16.1%) cases. Five (8.9%) patients underwent two-stage correction of the blood flow in the branches of the arch of the aorta and its thoracoabdominal segment. The clinical picture, the volume of the affection, the methods of examination, and techniques and the results of reconstructive operations are described in detail. The authors present their point of view on the performance of surgical treatment in stages in coexistent lesions differing in volume.     

Evaluation of profundoplasty in reconstructions of combined aorto-iliac and femoro-popliteal occlusive disease

The results in 135 patients undergoing aorto-iliac and aorto-femoral bypass during 1974-1979 were examined. In most cases, occlusive disease of the iliac arteries was combined with total atherosclerotic occlusion of the superficial femoral arteries and sometimes with additional pathology in the profunda femoris artery. In 18.7%, subsequent vascular procedures became necessary in extremities of patients who had undergone aorto-iliac or aorto-femoral anastomotic procedures without additional profundoplasties. In those cases where the primary reconstruction was combined with profundoplasty the results were very satisfying and subsequent procedures were needed only in 8.8%. The aorta-profunda femoris bypass is now preferred for patients with combined aorto-iliac and femoro-popliteal occlusive disease. Results and technical details are discussed.     

Laser angioplasty in the staged surgical treatment of patients with combined and multiple lesions of different arterial basins]

Percutaneous laser angioplasty was attempted in 30 patients with occlusive lesions of the main arteries of the lower extremities and the branches of the aortic arch. Most patients had either combined affection of the branches of the aortic arch and arteries of the lower extremities (56%), or involvement of several vascular segments on one extremity into the process (74%), or involvement of arteries of both lower extremities (85%). Seven patients underwent stage correction of circulatory cerebral disorders and restoration of patency of arteries of both lower extremities. Excimer laser on a wave length of 308 nm was used for angioplasty. Adequate operations were carried out in all cases without any complications in the postoperative period.     

A new technique of simultaneous revascularization of coronary vessels and lower limbs. 4 cases

Management of patients with concomitant coronary and aorto-iliac atherosclerosis is controversial. It is universally accepted that coronary artery surgery should precede aorto-iliac reconstruction. The technique described consists of an ascending aorta to bifemoral graft. This technique allows combined surgery of the coronary arteries and to the lower limbs without opening the peritoneum.     

Indications and choice of method of treatment of the lower extremities obliterating arterial atherosclerosis in elderly and senile patients with diabetes mellitus]

Results of treatment of 93 patients with diabetes mellitus and occlusive-stenotic affection of arteries of femoro-popliteal and popliteal-tibial segments were analyzed. Indications for performance of operation were established, basing on analysis of clinical manifestations of the disease and results of instrumental methods of investigation. Femoro-popliteal autovenous shunting performed in 47 (50.5%) patients, endarterectomy from the same segment--in 26 (28%), roentgenoendovascular dilatation of segments of femoral superficial and popliteal arteries--in 11 (11.8%), popliteal-tibial autovenous shunting--in 9 (9.7%). In 84 (90.4%) of patients succeeded to preserve the extremity. Postoperative lethality was 4.3%. Passability of autovenous femoro-popliteal-tibial shunts during 5 years was noted in 49.5%, passability of arteries after endarterectomy--in 38.7% of observations.     

Application of lumbar sympathectomy for the lower extremities diabetic angiopathy in presence of purulent necrotic changes on the foot]

Immediate results of treatment of 63 patients with diabetes mellitus and occlusion of main arteries of lower extremity on different level in chronic ischemia and presence of limited purulent-necrotic changes of toes were adduced. Indications for the operation performance were substantiated and immediate results were analyzed. Favourable result was achieved in 48 (76%) patients, fair--in 8 (13%), in 7 (11%) patients high amputation of extremity was done.     

Experiences in the use of eight cutaneous and osteocutaneous superficial and deep circumflex iliac free flaps

Eight patients underwent free tissue transfers involving groin cutaneous or osteocutaneous flaps using the superficial and deep circumflex iliac arteries and veins. Four were used for head and neck reconstruction, two for severe neck scar contractures, and two for composite skin and mandibular reconstruction. Three were used in lower extremity reconstructions, all in situations requiring bone and skin reconstruction. One was used for skin cover alone in an upper extremity reconstruction for wrist cover. One of the head and neck cases sustained vascular thrombosis requiring a second successful free flap coverage for a 12.5% failure rate. One required re-exploration with successful salvage. The average operating time was 12 hours. The anatomy and surgical techniques are discussed. The main values of the procedure are the presence of a double vascular supply of both arteries and veins for complex reconstructions, and the fact that a large area of skin and subcutaneous tissue can be procured, with a relatively inconspicuous donor site.     

Revascularized osteo-trepanation in the treatment of chronic occlusion of the lower extremities arteries

The results of operation of revascularized osteotrepanation (ROT) in complex of treatment of 43 patients with chronic occlusion of the lower extremities arteries were analyzed. Stable clinical effect after application of ROT in patients with the ischemia II stage persisted during 40 months, III stage--25 months, "high" amputation of lower extremity in patients with IV stage ischemia was performed in 3.5-7 months. ROT is operation of choice in patients with distal form of ischemia of lower extremity, as well as while presence of contraindications for performance of reconstructive operation on main arteries.     

56例腘动脉以下肢体动脉缺血的血管重建术分析

目的总结腘动脉水平动脉闭塞血运重建术治疗的临床疗效。方法对2001年7月至2005年8月56例累及腘动脉及腘动脉以下三分支病变重建肢体血运进行回顾性分析。根据病变阻塞平面不同,采用不同的血管架桥,对多平面、多节段动脉闭塞采用聚四氟乙烯人工血管和自体静脉桥复合序贯架桥血运重建。结果术后平均随访17个月,移植血管一期通畅率67．3％,二期通畅率78．8％。结论复合序贯搭桥术治疗累及股浅-腘动脉水平以下多节段（平面）动脉闭塞症是一种较实用的方法,可有效解决自体血管不足和单纯使用人工血管腘动脉以下血管重建通畅率差的问题。     

Mycotic aneurysms--A retrospective analysis]

12 patients (10 males and 2 females, average age 53 years) were operated upon in our hospital between 1994 and 1999 for mycotic aneurysms. The aneurysms were located in 7 patients in the aorto-iliac segment, 5 patients were treated for peripheral or visceral aneurysms. Two of these patients suffered from multiple aneurysms. When peripheral arteries were affected, a pulsatile tumour was felt. Most of these tumours developed in a relatively short period of time and sometimes a perivascular inflammation occurred. This was not the case when central arteries were attacked. A septic process or an infection, for example salmonella-enteritis, often preceded shortly the development of a mycotic aneurysm. In the case of an aneurysm of the aorto-iliac section we consider an in situ reconstruction with alloplastic material in combination with a perivascular debridement, lavage and omentum majus plastic as the treatment of choice. In peripheral arteries reconstruction should be performed with autologous vessels. Depending on the local findings, a perivascular debridement should also be performed in these cases. The reconstruction always should be combined with a calculated antibiotic therapy. Two of our patients died perioperatively. During follow up, 8 patients showed patent reconstructions and no signs of infection. The urgency of surgery depends on the level of inflammation and the existence of any secondary complications.     

Syndrome of diabetic foot and atherosclerosis of the lower extremity arteries

Obstructive damages of the peripheral arteries in diabetes mellitus patients are known to occur 4 times more often than in patients not having diabetes. For the recent 10 years 390 patients with serious decompensated diabetes mellitus and diabetic foot have been examined and treated. The atherosclerotic process in the low extremity arteries in diabetes mellitus patients was found to be more distally located, symmetrical and the ischemia signs were quickly progressing and badly answered to treatment. As a rule, sympathectomy and restoring operations were ineffective, often followed by necrotic alterations of the foot skin and gangrene. Our data have shown that even young patients with the main type of blood flow having the diabetic foot syndrome have certain signs of atherosclerotic affection of the low extremity arteries. It must be taken into consideration in their treatment.     

Comparison of computed tomography angiography to contrast arteriography for patients undergoing evaluation for lower extremity revascularization

In an effort to explore alternatives to contrast arteriography, we compared computed tomography angiography to contrast arteriography for defining anatomic features of patients undergoing lower extremity revascularization. From November 2003 to March 2004, 36 inpatients with chronic lower extremity ischemia underwent contrast arteriography and computed tomography angiography before undergoing lower extremity revascularization procedures. A Siemens 16 slice multiplanar computed tomography device with bolus tracking was used for these exams. The reports of these tests and images were compared prospectively, and the differences in the aorto-iliac segment, femoral-popliteal, and infrapopliteal segments were noted. The vessels were classified as mild disease (<50%), moderate disease (50%-70%), severe (71%-99%), and occluded. The studies and treatment plans based on these data were compared. The mean age was 76 +/- 12 years (SD). Indications for the procedures included gangrene (45%), ischemic ulcer (32%), rest pain (19%), and severe claudication (3%); 69% were diabetics. Accuracy of computed tomography angiography in the aorto-iliac, femoral-popliteal, and infrapopliteal segments was 100%, 81%, and 59%, respectively. Thirteen of 18 (72%) of these disagreements resulted in a different procedure than that suggested by computed tomography angiography. A review of the data obtained in this series indicated that computed tomography angiography appears to be unable to obtain adequate information in this highly selected population at our institution.     

Specific features of circulation in aorto-iliac arterial occlusion

On occlusion of aorto-iliac segment arteries the collateral circulation ensures an effective compensation of circulation in lower extremities and pelvic organs. The Doppler characteristics of the circulation in visceral and collateral ways of circulation are the subject of the study. The power of ultrasound duplex scanning to evaluate the regional hemodynamics on atherosclerotic occlusion of aorto-iliac segment vessels has been proved. The Doppler parameters of circulation in upper (UMA) and lower (LMA) mesenteric arteries and internal iliac artery (IIA) on high, moderate an low occlusion of abdominal part of aorta (APA) and on unilateral occlusion of iliac arteries have studied. Depending on the level and grade of extension of occlusion of main arteries the collateral circulation may increase in two or three times. Comparing volumetric velocity of circulation (VVC) in UMA and LMA in control group and in patients with low occlusion of APA an increase of VVC in the artery that has an opening situated directly near the proximal site of occlusion were revealed. These results are the evidence of functional remodelling of regional hemodynamics and of the presence of resources of collateral circulation on occlusional and stenothic lesion of aorto-iliac segment arteries.     

The potential of duplex scanning to replace aorto-iliac and femoro-popliteal angiography

The ability of duplex scanning to assess haemodynamically significant lesions in the aorto-iliac and femoro-popliteal arteries was studied. Duplex scanning was prospectively and independently compared to intra-arterial digital subtraction angiography (ia. DSA) of the aorto-iliac and femoro-popliteal arteries and intra-arterial pressure measurements of the aorto-iliac tract before and after the administration of papaverine. In 40 patients 629 arterial segments were evaluated. A greater than 150% increase in peak systolic velocity had a sensitivity of 92% and a specificity of 98% in detecting greater than 50% diameter reducing lesions in the aorto-iliac arteries as compared to ia. DSA. The numbers for the femoro-popliteal arteries are 88% and 98% respectively. Detection of occlusion in the aorto-iliac arteries had a sensitivity and specificity of 100% and in the femoro-popliteal arteries 90% and 100% respectively. There was a poorer correlation between intra-arterial pressure measurements and duplex scanning or ia. DSA as compared to the correlation between ia. DSA and duplex scanning. Retrospective spectral analysis showed that an end diastolic velocity (EDV) of greater than 40 cm/s seems to be a valuable parameter to differentiate between 50% to 74% and 75% to 99% diameter reduction. It is concluded that duplex scanning can reliably differentiate between haemodynamically significant and insignificant lesions in the aorto-iliac and femoro-popliteal arteries and has the potential to replace angiography.