From January 2006 to June 2008, 45 patients with lower extremity atherosclerosis were admitted to our hospital, among which 16 patients underwent different forms of arterial reconstruction bypass surgery, including 1 case of abdominal aorta-bifemoral artery artificial vessel bypass, 1 case of common iliac artery-femoral artery artificial vessel bypass bypass, 10 cases of femoral N artery bypass bypass. In 10 cases, 2 cases of femoral artery-posterior tibial artery autologous bypass and 2 cases of N vein arterialization were performed; all of them had different degrees of VCT ultrasound follow-up one month after the operation, which proved that the recent patency of the artificial vessels was good, but the long-term effect was to be further observed. In addition, 7 cases of interventional treatment were performed, including 4 cases of iliac artery stenting and 3 cases of posterior carotid artery balloon dilation of N artery. Dang Yongkang, Department of Vascular Surgery, Chifeng City Hospital
Therefore, surgical and interventional treatments have good therapeutic effects in different stages of atherosclerosis and in different patients, and it is especially important to choose different treatments according to the specific conditions of patients.
1. Clinical data
1.1 General information.
The group of 21 cases, 12 men and 9 women, age 53-74 years, etc., the average annual age of 63.5 years. The lower limbs all had different degrees of pain and cold sensation in the limbs for the longest 4 years and the shortest 3 months. Among the 21 cases in this group, 3 cases had simultaneous ischemic involvement of both lower extremities, and one of them received bilateral lower extremity femoral N bypass surgery. 21 cases had a history of hypertension in 14 cases (66.7%), diabetes mellitus in 16 cases (76.2%), hyperlipidemia in 11 cases (52.4%), smoking in 14 cases (66.7%), intermittent claudication were present for a maximum of ≤100 m in 15 cases, rest pain in 16 cases, toe ulcers in 4 cases.
1.2 Auxiliary examinations.
All 21 cases underwent lower extremity stage manometry with a mean ankle/brachial index (ABI) of 0.35 (0-0.83). 21 cases underwent color Doppler examination, which showed arterial stenosis changes in the lower extremities, most of which had larger plaques and inaccessible arterial flow. 21 cases underwent 64-row VCT, which could show the plane and length of significant arterial stenosis occlusion. DSA was performed in 6 patients to further clarify the plane and degree of arterial stenosis and occlusion. One case (4.8%) of bilateral iliac artery occlusion, 5 cases (23.8%) of right iliac artery occlusion, and 14 cases (66.7%) of superficial femoral artery occlusion were found.
1.3 Surgical approach.
All 16 cases in this group were treated with bypass surgery using artificial vessels from Beltran, Germany. 1 case was treated with bypass bypass surgery of the abdominal aorta and a double common femoral artery, 1 case was treated with bypass bypass surgery of the common iliac artery and femoral artery, 10 cases were treated with bypass bypass surgery of the femoral N artery, and 4 cases were treated with bypass bypass surgery of the lower femoral artery and posterior tibial artery by autologous vein.
1.4 Interventional treatment:
In this group, 7 cases and 4 cases of iliac artery occlusion underwent Intec balloon dilation Belan stent implantation; 3 cases of N artery posterior tibial artery Intec Deep balloon dilation.
1.5 Results.
There were no surgical deaths in this group, perioperative complications, one case of cardiac insufficiency, one case of pulmonary infection, one case of incisional infection,and one case of paralytic intestinal obstruction. In the postoperative follow-up period of 1-6 months, 15 cases had ultrasound examination and 2 cases had 64-row VCT examination. 20 cases had patency of blood vessels (artificial blood vessels and autologous veins) (100%), and the longest follow-up period of patients was one and a half years with patency of blood vessels. The symptoms of ischemia in the affected limb were significantly relieved after the surgery, the static and acute pain disappeared, the toes became warm and red, and the walking distance was significantly lengthened. The postoperative ABI improved to 0.78 (0.52-1.0).
2. Discussion
Lower extremity atherosclerotic occlusive disease (ASO) is a chronic arterial occlusive disease caused by atherosclerosis, which occurs in the lower abdominal aorta, iliac artery, femoral artery, N artery and other medium to large arteries affected extremities manifest as chills, numbness, pain, intermittent claudication, loss of arterial fluctuations, nutritional disorders, and ulcers or gangrene in the toe foot. Patients’ quality of life is seriously reduced, and even amputation. With the improvement of living standard, the change of diet structure, and the extension of life expectancy, this disease has become a rising trend and become a common and frequent disease in vascular surgery, especially the elderly are the most common. (1)
Lower extremity arterial occlusive disease mostly occurs between the ages of 50 and 70. The age of this group is 53-74 years old, with a mean age of 63.5 years old, and most of those who develop under 50 years old have other serious diseases combined. The main clinical manifestations of the patients were pain and coldness in the limbs, and in severe cases, claudication, resting pain, and even persistent ulcers. Ultrasound examination can detect the sclerosis and occlusion of blood vessels, which is necessary for the screening of this disease. In January 2006, our hospital introduced American GE 64-row VCT, which is simple, fast and economical for the diagnosis of vascular diseases and easy for patients to accept. 21 patients were examined, and it has a good effect on the site and degree of vascular lesions and the selection of localization surgical incision, and has replaced DSA as the first choice for the diagnosis of this disease. DSA is the gold standard for diagnosis before the emergence of VCT, as it can reflect vascular lesions from different angles. DSA was performed in three cases in this group, which is a good guide for diagnosis.
In terms of treatment, artificial vessel bypass surgery is still the first choice for long-segment femoral artery occlusion. 10 patients underwent this surgery, and the patency rates of artificial vessel bypass surgery were 77%, 63%, and 53% at 1, 3, and 5 years (2). One patient underwent artificial vascular bypass bypass of the abdominal aorta and double femoral arteries (VCT film available for double iliac artery occlusion). 5 days after surgery, paralytic intestinal obstruction was caused by excessive stretching of the abdominal intestinal canal, which was cured by one week of conservative treatment. Another case of common iliac femoral artery bypass surgery and six cases of femoral N bypass bypass surgery were successful. The key to successful surgery is to have sufficient pressure in the inflow channel and relatively unobstructed outflow channel, and most of these patients healed well. After rethrombosis, blood flow was restored and ischemia in the lower extremity improved significantly, and no reocclusion occurred 2 months after surgery. Two cases of autologous saphenous vein bypass, both of which were bypassed by the infrapopliteal posterior tibial artery, had good postoperative patency rates and no blockage of the autologous vessel at 3 months. Therefore, we believe that autologous vessels are preferred for infrapopliteal artery bypass, and artificial vessels should be used as little as possible. In terms of interventional treatment, the results of interventional treatment for short-segment iliac artery occlusion were good. For the five patients with iliac artery occlusion, four of them had interventional Belan stent implantation, which was less invasive and quicker to recover, and was easily accepted by the patients. It has the advantages of less invasion and faster recovery and is easily accepted by patients (5).
Patients with severe claudication (less than 100 m), resting pain, ischemic gangrene and long-term non-healing ischemic ulcers with or without diabetes mellitus should seek surgical or interventional treatment to save the affected limb, while explaining to the family that the purpose of treatment is mainly to preserve the limb, because atherosclerosis is a systemic disease and 30% of patients with ASO die from other cardiovascular diseases within 5 years (4).
Postoperative drug therapy has no therapeutic effect on atherosclerotic stenosis and occlusion per se, but it can play an important role in improving microcirculation by dilating blood vessels to promote the formation of collateral circulation, relieving pain and improving symptoms, avoiding or postponing reconstructive surgery, and maintaining the long-term patency of postoperative vessels. Patients need postoperative antiplatelet therapy, poliovir, aspirin, which can be chosen according to the patient’s economic condition.
Patients with venous arterialization need to be anticoagulated with warfarin. One patient treated with poliovir and antiplatelet therapy developed thrombosis in 1 month, and after surgical removal of the thrombus, the anticoagulation was changed to warfarin and no recurrence of thrombosis occurred in 5 months.
From the above cases we conclude that femoral artery occlusion of long segments is preferable to femoral N bypass bypass surgery. Iliac artery occlusive lesions are better treated with endovascular stenting (PTA), which is popular among patients because of its advantages such as less invasive and repeatable; the disadvantage is that it is expensive. arterial occlusive lesions below the N artery Intech Deep balloon dilation, is a good choice.
Therefore, early diagnosis of atherosclerotic occlusive disease (VCT; DSA) treatment will mostly have a better healing, and choosing the appropriate surgical or interventional treatment modality according to the extent of the lesion site is extremely important for the patient’s prognosis.
References
1, Wang Zhonghao, Zhang Jian, eds. Practical Vascular Surgery and Vascular Interventional Therapy, First Edition, Beijing, People’s Military Medical Press, 2004, 254-259.
2, 4, Wang Yuqi, Surgical treatment problems of lower extremity atherosclerotic occlusive disease, Chinese Journal of General Surgery, 2003, 18, 4, 197-198.
3, Yu Hengxi, Dong Zongjun et al, Clinical analysis of 76 cases of chronic arterial ischemia of the lower extremities treated by artificial vascular bypass, Chinese Journal of General Surgery, 2003, 18, 4, 199-200.
5,Jing Zaiping, ed. Endovascular Endovascular Therapy, First Edition, Beijing, People’s Health Press, 2002, 228-230.