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Lower limb revascularization criteria trough the profound femural artery in polisegmentary atherosclerotic lesions in patients with critical ischaemia


Author: Ţurcan Aurel
Degree:doctor of medicine
Speciality: 14.00.27 - Surgery
Year:2009
Scientific adviser: Nicolae Gladun
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution:
Scientific council:

Status

The thesis was presented on the 29 April, 2009
Approved by NCAA on the 18 June, 2009

Abstract

Adobe PDF document1.11 Mb / in romanian

Thesis

CZU 617.58:616.137.83-004.6-005.4(089)

Adobe PDF document 4.43 Mb / in romanian
128 pages


Keywords

Obliterative atherosclerosis - critical ischaemia of the lower limbs - polisegmentary lessions - profound femoral artery - profound-aortal index

Summary

This work emphasizes the surgical treatment results of 750 patients with critical lower limb ischaemia caused by arterial polisegmentary atheroscletotic lesions in the period 1998-2005. Of all patients with critical ischaemia included in this study, 350 (46,6 %) were in the control group, and 400 (53,3 %)- in the study group. All patients from both groups were investigated and underwent complex treatment. The majority of patients were men aged between 16 and 83. 279 (69,7 %) patients from the study group and 273 (78 %) of patients from the control group were aged between 45 and 65, thus representing the working class.

There has been proposed a new diagnostic and treatment algorithm for assessing patients with critical lower limb ischaemia, that differs from the classical algorithms (European Consensus TASC, Russian Consensus), by introducing a new diagnostic index (the profundo-aortal index), which is an objective prognostic criterion for revascularizations through the profound femoral artery.

There also have been made some changes in the Fontaine-Pokrovski classification of critical ischaemia. The IV-th degree of ischaemia has been divided in two subgroups:
-IV “a” degree – necrotic ulcer or gangrene limited to 2/3 of the foot tissues or extending to the tarso-metatarsal articulation – thus revascularization is necessary;
-IV “b” degree – necrotic changes or gangrene extending more than 2/3 of the foot tissues or that extends proximal from the tarso-metatarsal articulation – thus primary amputation is necessary.

The profundo-aortal index represents the ratio between the sum of the isthmic diameter of the profound artery, the external diameter of the permeable segment of the profound femural artery, the internal diameter of the permeable segment of the profound femoral artery and the sum of the aortic diameter at the level of the renal arteries and the bifurcational aortic diameter. According to the results of this study, in patients with the profundo-aortal index more than 0,3, a successful revascularization through the profound femoral artery is possible (good results in 96,5 % cases). In patients with the profundo-aortal index less than 0,3, an accessory femuro-distal by-pass is indicated in the same surgical session.

According to the results of the study, there has been a change in the structure of the surgical approaches, thus reducing the number of unsuccessful operations in the study group compared to the control group.
-The rate of double reconstructions has increased in the study group (26 – in the study group compared to 6 in the control group), thus avoiding repeated surgery in patients with unsuccessful revascularization operations through profunda femuris artery.
-The rate of aorto-femural by-passes has increased at the expense of ileo-femural by-passes, the last being less durable in time
-New reconstruction methods were implemented. Successful femuro-femuro profundal by-passes were applied to 24 patients from the study group.

Thus, changing the investigation and diagnosis algorithm, as well as elaborating objective criteria for determining the possibilities of revascularization through the profound femoral artery, and changing the classification of lower limb chronic ischaemia, has led to the improvement of surgical treatment results in patients with critical lower limb ischaemia caused by polisegmentary atherosclerotic lesions in the study group compared to the control group: