Surgical treatment of abdominal aortic aneurysm in combination with obliterating atherosclerosis of the lower extremities

Abstract

The treatment of abdominal aortic aneurysms in combination with obliterating atherosclerosis of the lower extremities is a very difficult problem in the definition of surgical approach. Its caused by increased frequency of atherosclerosis as the basis of this disease, old age and the presence of comorbidities, especially coronary heart disease (CHD), which determines the capabilities of this treatment and its prognosis.

The aim of this research was to analyze the results of diagnostics and treatment of the patients with abdominal aortic aneurysm in combination with obliterating atherosclerosis of the lower extremities.

Materials and methods: The research was conducted during the past 20 years in the Department of Vascular Surgery in Zaporizhzhya Regional Clinical Hospital in the age group of 40 to 80 years. 92 patients had aneurysm of the abdominal aorta in combination with obliterating atherosclerosis of the lower extremities. In this study were analyzed the results of treatment of the patients who underwent surgery only in a planned manner. All of them had manifestations of the lower limbs ischemia and severe comorbidities. Herewith, 8 patients had occlusion of the iliac arteries on both sides and 15 patients had occlusion of the iliac arteries on one side. 87  patients had iliac artery stenosis of varying severity. 53 patients from the same group had occlusion of the superficial femoral artery with the deep femoral artery stenosis. Choice of the surgical method was determined by the data of aneurysm’s state in the dynamics received by instrumental methods, the presence of comorbidities, patient’s age, the state of vital functions and the risk of bleeding and restore of the lower limbs circulation. The basic way of surgical interventions for abdominal aortic aneurysm in combination with obliterating atherosclerosis of the lower extremities was a resection of the aneurysm with opening of the aneurysmal bag and prosthetics of the aorta. Aorto-aortic (linear) prosthesis was performed in a case of spreading the aneurysm to the bifurcation of the aorta and absence of severe stenosis or dilatation of the iliac arteries; aortoiliac bifurcation prosthesis - in patients with severe lesions of common iliac arteries, aneurysmal expansion or occlusive-stenotic process but in a case of adequate arteries; aortofemoral bifurcation prosthesis - in a case of total injury of common and external iliac arteries by aneurysmal or stenotic process. To stabilize the results of surgical treatment in postoperative period were appointed drugs that can improve blood circulation in the lower extremities. Use of stent-grafts has not found widespread clinical application, so native experience in restoration of a blood flow in stenotic or occluded arteries using stents - grafts is still too young to be able to do any definitive conclusions about all the possibilities of this method of treatment, but the low invasiveness and relative ease of replacement demonstrate its clear advantages, and high clinical efficacy will include intravascular technology to the tactics of the "first choice."

The results and discussion: The results of surgical treatment of aneurysms of the abdominal aorta in conjunction with obliterating atherosclerosis were positive in 84 of 92 patients. Postoperatively, 7 patients (7.5%) died from the acute cardiovascular failure. One patient had a myocardial infarction with symptoms of acute cardiovascular collapse with cardiac arrest, resuscitation measures were effective, the patient has recovered. The relief of the process was achieved in all patients who had chronic ischemia of the lower limbs.

Conclusions: The presence of abdominal aortic aneurysm, regardless of its size in combination with obliterating diseases of the arteries of the lower extremities is an absolute indication for surgery. Choice of the surgical method in a case of combination of abdominal aortic aneurysm with obliterating atherosclerosis is strictly individual and should be aimed at the elimination of the aneurysm as a possible source of bleeding and at the restore of the circulation in the lower extremities. Modern approaches in patient’s preparations for surgery and choice of treatment allowed us to get positive results in 91.3% of the patients.