Opportunities for improvement of distal autologous reconstructions in patients with chronic critical limb ischemia

Authors

  • O. I. Gudz Ivano-Frankivsk National Medical University, Ukraine,

DOI:

https://doi.org/10.14739/2310-1210.2019.1.155809

Keywords:

arterial occlusive disease, lower limb, reconstructive surgery

Abstract

Study objective: to evaluate the diagnostic capabilities of spiral CT-angiography (CTA) for planning of autovenous distal arterial reconstruction (DAR) and to develop intraoperative techniques aimed at reducing the negative effect of traumatic processes of harvesting and preparation of the great saphenous vein in patients with chronic critical limb ischemia (CCLI).

Materials and methods. DARs were performed in 176 patients with manifestations of CCLI. Before the surgery, 48 patients underwent CTA with an additional venous phase to study the morphological changes and size of the great saphenous vein (GSV) as a bypass material. During DAR procedures, we evaluated the effectiveness of our own approach to the harvesting and subsequent preparation (pharmacological dilation) of GVS as a vein graft.

Results. CTA performing using 2-phase mode served to detect morphological changes (hypoplasia, varicose transformation) and determine the diameters of GSV at three levels of the thigh with high accuracy. The obtained data were correlated (the lowest index - r = 0.58) with the results of ultrasound examination of the vein size on the thigh. The diagnostic value of CTA in the planning of autovenous shunting was 89.8 ± 2.9 %.

Taking into account the GSV anatomical location, the Vollmar ring dissector was used for less traumatic GSV harvesting. This allowed reducing the number and size of skin incisions, preventing lymphatic basins and cutaneous nerves damage and making the GSV harvesting less traumatic for thigh soft tissues. The use of a vasodilators solution in the process of GSV preparation for DAR managed to avoid the destructive effect of hydraulic vasodilation on the venous endothelium functional state. A formula was proposed to predict an increase in lumen of vein graft during pharmacological vasodilation performing.

Conclusions. CTA performing using a special mode (arterial and venous phases) in DAR planning for patients with CCLI, allows a high reliability of GSV suitability evaluation for autologous bypass surgery. It is possible to reduce the surgical injury during GSV for DAR harvesting and preparation procedures by using a ring dissector for careful preparation as well as by dilating the vein graft lumen not by the usual mechanical method but by a pharmacological one.

References

Bisdas, T., Borowski, M., Torsello, G. (2015). Current practice of first-line treatment strategies in patients with critical limb ischemia. Journal of Vascular Surgery, 62(4), 965–973.e3. doi: 10.1016/j.jvs.2015.04.441.

Malyar, N., Fürstenberg, T., Wellmann, J., Meyborg, M., Lüders, F., Gebauer, K., et al. (2013). Recent trends in morbidity and in-hospital outcomes of in-patients with peripheral arterial disease: a nationwide population-based analysis. European Heart Journal, 34(34), 2706–14. doi: 10.1093/eurheartj/eht288.

Skonetzki, S., Lüders, F., Engelbertz, C., Malyar, N., Freisinger, E., Meyborg, M. & Reinecke, H. (2016). Aging and Outcome in Patients With Peripheral Artery Disease and Critical Limb Ischemia. Journal of the American Medical Directors Association, 17(10), 927–32. doi: 10.1016/j.jamda.2016.06.004.

Jaff, M., & Weinberg, I. (2016). How to Treat Critical Limb Ischemia. JACC: Cardiovascular Interventions, 9(24), 2566–2567. doi: 10.1016/j.jcin.2016.10.005.

Popplewell, M., Davies, H., Jarrett, H., Bate, G., Grant, M., Patel, S., et al. (2016). Bypass versus angio plasty in severe ischaemia of the leg - 2 (BASIL-2) trial: study protocol for a randomised controlled trial. Trials, 17, 11. doi: 10.1186/s13063-015-1114-2.

Farber, A., Rosenfield, K., & Menard, M. (2014). The BEST-CLI Trial: A Multidisciplinary Effort to Assess Which Therapy is Best for Patients With Critical Limb Ischemia. Techniques in Vascular and Interventional Radiology, 17(3), 221–224. doi: 10.1053/j.tvir.2014.08.012.

Ballotta, E., Toniato, A., Piatto, G., Mazzalai, F., & Da Giau, G. (2014). Lower extremity arterial reconstruction for critical limb ischemia in diabetes. Journal of Vascular Surgery, 59(3), 708–19. doi: 10.1016/j.jvs.2013.08.103.

Harskamp, R. E., Alexander, J. H., Schulte, P. J., Brophy, C. M., Mack, M. J., Peterson, E. D., et al. (2014). Vein graft preservation solutions, patency, and outcomes after coronary artery bypass graft surgery: follow-up from the PREVENT IV randomized clinical trial. JAMA Surg., 149(8), 798–805. doi: 10.1001/jamasurg.2014.87.

Li, F. D., Eagle, S., Brophy, C., Hocking, K. M., Osgood, M., Komalavilas, P., & Cheung-Flynn, J. (2014). Pressure Control During Preparation of Saphenous Veins. JAMA Surgery, 149(7), 655–62. doi: 10.1001/jamasurg.2013.5067.

Osgood, M., Hocking, K., Voskresensky, I., Li, F., Komalavilas, P., Cheung-Flynn, J., & Brophy, C. (2014). Surgical vein graft preparation promotes cellular dysfunction, oxidative stress, and intimal hyperplasia in human saphenous vein. Journal of Vascular Surgery, 60(1), 202–211. doi: 10.1016/j.jvs.2013.06.004.

Hudz, O. I., & Tkachuk, O. L. (2015). Zastosuvannia velykoi pidshkirnoi veny yak materialu dlia dystalnoho shuntuvannia za krytychnoi ishemii tkanyn nyzhnoi kintsivky [Application of Large subcutaneous vein as a material for distal shunting in critical ischemia of the lower extremity tissues]. Klinichna khirurhia, 4, 44–46. [in Ukrainian].

Winkler, B., Reineke, D., Heinisch, P. P., Schönhoff, F., Huber, C., Kadner, A., et al. (2016). Graft preservation solutions in cardiovascular surgery. Interactive Cardiovascular and Thoracic Surgery, 23(2), 300–309. doi: 10.1093/icvts/ivw056

How to Cite

1.
Gudz OI. Opportunities for improvement of distal autologous reconstructions in patients with chronic critical limb ischemia. Zaporozhye Medical Journal [Internet]. 2019Feb.8 [cited 2024May20];(1). Available from: http://zmj.zsmu.edu.ua/article/view/155809

Issue

Section

Original research