Arteriosclerosisobliterans (ASO) is a common disease in vascular surgery, which is an important cause of limb ischemia and one of the main causes of disability in the elderly. In recent years, with the development of interventional technology, endoluminal interventional treatment for atherosclerotic occlusions has been widely carried out in China. It has greatly alleviated the pain of patients and reduced the rate of amputation. From 2004.2 to 2012.9, 157 patients (166 limbs) were treated with endoluminal interventions in our hospital. The good results are reported as follows.
1. Clinical data
1.1
General data:
There were 166 limbs (158 lower limbs and 8 upper limbs) in this group of 157 patients, 101 males and 56 females. Age 45-86 years, mean age 68.5 years. At admission, 62 patients had resting pain, 46 of them had infection or dry gangrene of the foot, 82 had intermittent claudication, 72 of which had a claudication distance of less than 200 meters. The medical history was combined with hypertension in 124 cases and diabetes mellitus in 68 cases. Physical examination of 156 limbs: the radial artery, dorsalis pedis and posterior tibial artery of the diseased limb were not pulsating, and the skin temperature of the affected limb was decreased.
1.2
Preoperative examination
All patients underwent CT angiography before surgery. There were 1 occlusion of the left brachial artery, 7 occlusion of the subclavian artery, 51 occlusion of the iliac artery, 81 occlusion of the common and superficial femoral arteries, 46 of which were accompanied by occlusion of the anterior or posterior tibial artery below the knee, and 26 occlusion of the national artery and below. All cases were confirmed by arteriography before endoluminal intervention.
1.3
Surgical method
The affected side was selected as the puncture point in 91 limbs, and the contralateral side was selected as the puncture point in 67 cases. The right femoral artery was chosen as the puncture point in all patients with subclavian and brachial artery occlusion. After successful puncture of the femoral artery, a guidewire was inserted, and a contrast catheter was placed along the guidewire to clarify the lesion before the lesion was made. The guidewire and catheter were passed through the occlusion.
The method of endoluminal intervention was decided according to the lesion. In this group, 50 patients with iliac artery occlusion and 20 patients with common femoral artery occlusion were treated with 8 mm diameter balloon expansion followed by placement of 8 mm stents (Bard, Beltran, EV3, Intec), including one occlusion of approximately 14 cm in length, and one stent each of 10 cm and 8 cm in length. 34 patients with superficial femoral artery, 7 patients with subclavian artery and 1 patient with brachial artery occlusion were treated with 6 mm balloon expansion followed by placement of 6 mm stents were placed.
In 23 patients with occlusion of the superficial femoral artery and 7 patients with occlusion of the national artery, balloon dilation was performed alone. In one case, the superficial femoral artery was severely occluded, and the deep femoral artery was occluded at the beginning, so balloon dilation of the deep femoral artery was performed. Of the 46 cases of femoral artery occlusion with occlusion of the anterior or posterior tibial artery below the knee, 27 cases were treated with femoral artery occlusion followed by dilatation of the anterior or posterior tibial artery with a 2.5-3 mm diameter Deep balloon, and 26 patients with occlusion below the national artery were dilated with a 2.5-3 mm diameter Deep balloon. All were re-imaged throughout before the end of the intervention. The puncture site was dressed with pressure.
1.4
Postoperative management
All cases were anticoagulated with low molecular heparin for 2-5 days postoperatively (40 mg q12h days), after which they were switched to oral warfarin. Coagulation images were checked periodically to adjust the dose of medication, and PT-INR was controlled between 2-3 as appropriate.
2. Results
One patient with inferior bifurcation occlusion of the national artery and one patient with long segment occlusion of the superficial femoral artery were amputated due to failure of the guidewire to pass through the occluded segment, 117 limbs recovered dorsalis pedis or posterior tibial and radial artery pulsation, and 157 limbs had elevated skin temperature. Resting pain disappeared in all successful cases. There were no deaths in this group. In 7 cases, hematoma developed at the dilated area after pressure dilation using a pressure syringe, which improved after conservative treatment.
Four cases developed individual toe ischemia due to small plaque detachment, which improved after dilation. The postoperative hospital days ranged from 2-12 days, with a mean of 2.59 days. At 3-40 months follow-up, 8 patients were obstructed by in-stent thrombosis, of which 2 were reballooned and dilated, 4 had their limbs preserved after anticoagulation and thrombolysis, and 2 had their limbs amputated. The ischemic symptoms improved or disappeared in other patients.
3. Discussion
ASO is a chronic arterial occlusive disease caused by atherosclerosis, which is common in the elderly and occurs in large and middle arteries such as iliac artery, femoral artery, national artery, subclavian artery and common carotid artery. As the disease progresses, it often causes intermittent claudication, resting pain, and gangrene of the distal limbs. It is one of the main causes of disability in elderly patients, and in severe cases, it can be life-threatening due to toxin absorption and infection from limb necrosis.
The traditional approach for chronic limb ischemia is arterial bypass and endothelial dissection, but patients of advanced age or with combined cardiopulmonary disease often cannot withstand the blows of surgery and anesthesia, while arterial bypass with an anastomosis located below the knee has unsatisfactory long-term patency rates. Since Dotter first introduced percutaneous transluminal angioplasty (percutaneous angioplasty) in 1964
Since Dotter first applied the percutaneous transluminai angioplasty (PTA) technique to clinical practice in 1964, the PTA technique has been rapidly developed with the development of interventional materials. Because of its minimally invasive and reproducible nature, PTA has become an important tool for the treatment of vascular diseases. Balloon dilation and endoluminal stent implantation are now superior to arterial bypass surgery in some superior knee artery lesions.
Patients with ASO have different sites and lengths of arterial occlusion, so the choice of interventional procedures and the placement of stents is a question for the vascular surgeon and is directly related to whether the patient’s limb ischemia can be improved. Nowadays, the long-term patency rate of PTA for short occlusions (within 5 cm) of the iliac and femoral arteries is not significantly different from that of arterial bypass, and some data even suggest that the long-term patency rate of PTA is higher than that of arterial bypass.
For such occlusions PTA has gradually replaced arterial bypass. In patients with long-segment occlusions of the iliac and femoral arteries, the choice of intervention should be based on the patient’s systemic status because the patency rate after PTA is lower than that of arterial bypass.
The treatment of occlusion of the national and tibiofibular arteries used to be a difficult problem for vascular surgery. In this group, 53 cases of national artery occlusion were treated by simple dilation of the deep small balloon, and good results were achieved.
Because of the small caliber of the arteries below the N artery, the patency rate after stent implantation is not satisfactory, and simple balloon dilation has repeatable treatment, making the placement of stents controversial. We believe that the occluded segment of the superior iliac and femoral arteries is between 2 and 15 cm, and the occluded segment is retracted after balloon dilation, so stent placement is necessary. In our group of stenting cases, the longest occluded segment was 14 cm, and two stents were inserted after balloon dilation.
However, in cases where the occluded segment of the iliac and femoral arteries is less than 2 cm and there is no retraction after dilation, stenting would greatly increase the cost of treatment for the patient, and the difference in the long-term patency rate is not significant, so it is questionable whether stenting is necessary. Stent placement is generally not advocated for occlusions of long segments of the iliac and femoral arteries (more than 15 cm) and occlusions of the national and tibiofibular arteries.
In patients with atherosclerotic occlusion, the deep femoral artery is important for limb preservation. When the superficial femoral artery is occluded, a collateral circulation is formed between the deep and superficial femoral arteries thereby increasing the blood supply to the distal limb. When the superficial femoral artery cannot be opened, resolution of the occlusion and stenosis of the deep femoral artery may also allow for limb preservation in some patients.
The success of interventional treatment of ASO depends not only on the site and length of the occlusion, but also on the operator’s experience and postoperative management.
We believe that the following points should be noted during interventional and postoperative treatment.
(1) The operator should be skilled in interventional techniques and select appropriate puncture sites and catheters and guidewires intraoperatively.
(2) The operator should have the necessary patience during the operation and should not operate roughly.
(3) If an entrapment is formed during the puncture, carefully adjust the direction of the guidewire, gently probe around and contrast at any time, and most of them can re-enter the true lumen.
(4) Select a balloon of appropriate diameter according to the site of the dilated artery, and the length of the balloon should exceed the length of the occlusion as much as possible to avoid continuous and repeated dilatation of short balloons.
(5) Vascular surgery for atherosclerotic occlusion only solves the problem of distal blood supply, atherosclerosis itself will further develop as the patient ages, and with the small range of motion of elderly patients, mild ischemia will not have an impact on the patient’s life, so do not overly pursue imaging perfection during surgery, leading to unnecessary injuries and complications.
(6) For the same reason, interventional treatment is not advocated for elderly patients with a claudication distance of 200 meters or more, and conservative treatment with drugs is recommended first.
(7) Intraoperative heparin was given intravenously for anticoagulation, and the dose we used was 0.8 mgkg.
(8) Before the end of the intervention, the whole process should be re-imaged to understand the patency and whether there is any distal thrombus or detached plaque leading to arterial embolism.
(9) In patients with diabetes mellitus with tibiofibular artery occlusion, patency of one artery may not be sufficient and as many as possible should be opened.
(10) Postoperative anticoagulation is necessary for long term patency after PTA. We adopt the postoperative use of low molecular heparin for 2 days (4000u q12h), followed by long-term oral warfarin anticoagulation. To reduce the chance of in-stent thrombosis.
Endoluminal interventions for ASO are gaining clinical attention because of their minimally invasive and reproducible nature, which also reduces the risk and trauma associated with patient treatment. It reduces the postoperative hospitalization time of patients, and the average postoperative time in this group is 2.59 days, which is much lower than the average hospitalization time of 8.4 days for patients undergoing bypass surgery in the same period. With the emergence of new interventional techniques and materials, the use of PTA will be further expanded and the long-term patency rate will be improved.