Method for diagnosing functional completeness of vascular anastomosis after performing surgical interventions

FIELD: medicine.

SUBSTANCE: method involves determining hemodynamic characteristics of blood circulation in vascular anastomosis area in standard zones distal and proximal with respect to the vascular anastomosis by means of ultrasonic dopplerography during the first 6 months, after vascular plastic operation being applied. Dynamic changes in the characteristics are interpreted in terms of full-valued vascular anastomosis condition.

EFFECT: high accuracy of diagnosis; high accuracy of ultrasonic blood circulation condition criteria.

11 dwg, 2 tbl

 

The invention relates to medicine, namely to clinical research methods using ultrasound, and can be used to diagnose the functional usefulness of vascular anastomosis after reconstructive surgery.

One of the most important problems of reconstructive vascular surgery is the issue of thrombosis shunts and prosthetic reconstruction of blood pools. According to literature data the main reason for their development in the first 3-6 months after surgery is the proliferation of neointima in the area of the anastomosis, which narrows the lumen of the reconstructed arterial section, violates the hemodynamics in this area with the development in the end of the thrombotic process. This is especially true when performing vascular reconstructions in the distal limb of the smaller peripheral arteries, particularly in the femoral-popliteal position when 1 year after such interventions operates only 40-60% of shunts.

In this regard there is an urgent need for timely diagnosis narrow the line of anastomosis that may allow you to take timely and appropriate therapeutic measures for preventing the progression of thrombotic complications.

Currently, the main method of diagnosis of pathological changes and prohodimec and main arterial bed is x-ray contrast angiography. However, angiography has significant deficiencies widely use in various populations of patients. The main disadvantage of angiographic study is its invasiveness, which can lead to a variety of vascular complications (thrombosis, intimal dissection, bleeding, and other), and severe allergic reactions, life-threatening patient (anaphylactic shock, angioedema, and others).

In recent years more and more widely used non-invasive methods of visceral blood flow and, in particular, electronic, and magnetic resonance imaging, allowing to detect stenotic changes in the vessel lumen with an accuracy of up to 70% (D. Ropers, Regenfus m, Stilianakis n et al.//A direct comparison of noninvasive coronary angiography by electron beam tomography and navigator-echo-based magnetic resonance imaging for the detection of restenosis following coronary angioplasty// Invest. Radiol. - 2002. - Jul. - Vol. 37(7). - P.386-392). However, the high cost of research, on the one hand, and the impossibility of identifying the pathological process in its early stages, on the other, in connection with the registration of purely organic changes of the endothelium, limit the application of these methods.

In this regard, important in the diagnosis of patients who underwent reconstructive surgery on peripheral arteries of the extremities, is the study of the functional state formed vascular Ana is tomasov, that may help to identify their pathological changes in the earlier stages, i.e. before the development of visually recorded proliferative changes.

Thus, the method of ultrasonic diagnostics of the degree of chronic arterial insufficiency of the extremities, based on the change in the value placelocation index when performing nursing standard physical exercise on a treadmill - the treadmill (Zatevakhin I.I., tsitsiashvili MS, zalkin NR. and other//a New approach in the assessment of severity KHAN in patients with limiting "intermittent claudication"//Angiology and vascular surgery. - 1997. - Volume 2 (Appendix). - P.7-8).

However, this method, recording the overall degree of ischemia of the lower extremities, can only roughly estimate the functionality of a particular vascular anastomosis.

The most informative of these positions method is the determination of the allowance fractional blood flow directly within the study area (Pijis N.H., Klauss V., Siebert U. et al.//Coronary pressure measurement after stenting predicts adverse events at follow-up: a multicenter registry// Circulation. - 2002. - Jun. - Vol. 105(25). - P.2950-2954). Its essence lies in the catheterization analyzed arterial segment and the direct determination of the flow velocity and the pressure gradient in the study of the vascular pool. The method adopted by us for the prototype.

However, the way that-p is totip and has significant disadvantages, the main of which is associated with the invasiveness of the technique with all the above possible complications, which complicates its use for dynamic control over the patient.

The aim of the invention is to develop a clear ultrasound criteria for the diagnosis of the functional usefulness of vascular anastomosis after reconstructive surgery.

This goal is achieved by the fact that the patient in the postoperative period after reconstructive vascular surgery using ultrasonic dopplerography (USDG) determine the hemodynamic characteristics of blood flow proximal and distal to the vascular anastomosis and change is judged on the degree of functioning of the vascular anastomosis.

New in the invention is that by means of ultrasound measured blood flow velocity in the standard zones of proximal and distal vascular anastomoses, which reflects the intensity of the arterial blood flow and functionality of the region of the vascular reconstruction.

The proposed method is as follows.

To measure the speed of blood flow through the major arteries and vascular lower limb prostheses used linear transducer with a frequency of 7 MHz apparatus Akuson-128" (USA).

The nearest polioviral nom period (7-10 days after reconstructive surgery) was visualized area of the anastomosis and measured hemodynamic parameters of blood flow immediately proximal and distal to the formed vascular anastomosis. The parameters we considered:

- V max is the maximum flow recorded in the systole of the heart;

- V min - the minimum blood flow velocity, reflecting hemodynamics during diastole of the heart;

- TMH - time-averaged blood flow velocity;

- Pi - index positively;

- Ri is the resistance index.

For more accurate topical diagnosis of possible pathological process we necessarily investigated as proximal and distal anastomoses (Fig. 1). Important, in our opinion, it seems that to increase the information content of our proposed method and the possibility of performing the procedure in the dynamics, the necessary measurement parameters of arterial blood flow must be performed in the standard areas directly at the site of vascular anastomosis (figure 2-5).

The results of our research in the immediate postoperative period allowed to judge the functional usefulness of vascular anastomoses and to identify their initial narrowing due to possible errors in surgical technique. Next to the patient on a monthly basis throughout the most "dangerous" from the point of view of proliferation neointima period conducted identical survey proximal and distal anastomoses and change the obtained blood flow parameters were judged on time is the United stenotic process line vascular anastomosis.

The invention explain the following clinical examples.

Example 1.

Patient, 53 years of age, No. istby. 276, at admission to the clinic complaining of pain in the right calf muscle while walking at a distance of about 100 m, the cooling of the right foot and Shin.

The patient underwent direct the aorto-arteriography, which revealed extensive occlusion of the right superficial femoral artery from the mouth to the lower third of the thigh (6, 7). Diagnosed with obliterating atherosclerosis of lower limb arteries, occlusion of the right superficial femoral artery chronic arterial insufficiency of the extremities PB Art.

The patient made the right femoral-popliteal bypass with a positive effect on clinical manifestations of chronic ischemia of the right lower limb regressed the index of regional systolic pressure on the posterior tibial artery was 120%of the anterior tibial artery - 110%.

On day 7, and 1 month after surgery, performed a study of hemodynamic characteristics of vascular anastomoses by our proposed method (table 1).

Found that on the 7th day after the operation there is a significant increase in the linear velocity of blood flow in the distal zones of both anastomoses compared to proximal areas. So poppy is emalina the speed of blood flow in the proximal anastomosis increased to 100.00%, minimum - 83,33%, and the medium on 92,59%. In the distal anastomosis, these figures were respectively 64,81, 50.00, and 59,09%.

At 1 month after surgery, the difference of the velocities in the proximal and distal zones of both anastomoses became less pronounced and decreased on average by 20%. In the future, during the 6 month observation of the tested parameters remained approximately at the same level, indicating that there was no progression of the narrowing lines of anastomoses in the patient in the postoperative period. A significant increase in the linear velocity of blood flow on day 7 after surgery shows, apparently, on the development of reactive inflammatory process in the field of vascular anastomoses in the immediate postoperative period with recourse hemodynamic disturbances through 1 month after reconstructive intervention as subacute inflammation. A smooth and gradual increase in the linear velocity of blood flow through the main artery from the common femoral to popliteal during the whole period of observation is physiological and irrefutable evidence about the correct selection of the diameter of the vascular prosthesis and the absence of errors in surgical technique when applying vascular anastomoses.

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Table 1.

Hemod najczesciej indicators proximal and distal anastomoses patient K. (example 1).
StagesIndicatorsThe proximal anastomosisThe distal anastomosis
Procs. areaDiest. area% changed.Procs. areaDiest. area% changed.
7 daysV max (m/s)0,611,22+100,000,540,89+64,81
V min (m/s)0,120,22+83,330,080,12+50,00
TAMH (m/s)0,270,52+92,590,220,35+59,09
Pi1,811,92+between 6.082,092,20+5,26
Ri0,800,82+2,500,850,87+2,35
1 monthV max (m/s)0,590,95+61,020,530,74+39,62
V min (m/s)0,110,18+63,640,070,10+42,86
TAMH (m/s)0,25/td> 0,46+84,000,210,29+38,10
Pi1,921,69-11,052,242,23-0,45
Ri0,810,810,000,870,86-1,15
2 monthsV max (m/s)0,600,97+61,670,540,73+35,19
V min (m/s)0,120,19+with 58.330,080,11+37,50
TAMH (m/s)0,260,48+84,620,220,30+36,36
Pi1,851,63-11,892,092,07-0,96
Ri0,800,800,000,850,850,00
3 monthsV max (m/s)0,580,96+65,520,520,72+38,46
V min (m/s)0,110,17+54,550,070,11+57,14
TAMH (m/s)0,24+87,500,200,28+40,00
Pi1,961,76-10,202,252,18-3,11
Ri0,810,82+1,230,870,85-2,30
6 monthsV max (m/s)0,580,92+58,620,520,71+36,54
V min (m/s)0,100,16+60,000,070,10+42,86
TAMH (m/s)0,230,42+82,610,200,27+35,00
Pi2,091,81-13,402,25of 2.26+0,44
Ri0,830,830,000,870,86-1,15
Note: V max is the maximum linear speed;

V min - the minimum linear speed;

TMH - average linear speed;

Pi - index positively;

Ri is the resistance index.

This example illustrates the great opportunities our proposed method in the diagnosis functionality is Noah usefulness of vascular anastomoses, allowing them dynamic control over the entire observation period after reconstructive procedures.

Example 2.

Patient G., 50, No. istby. 342, at admission to the clinic complaining of pain in the left calf muscle while walking at the distance of 50-100 m, the cooling of the left foot and Shin. The patient underwent direct the aorto-arteriography, which revealed extensive occlusion of the left superficial femoral artery (figure 10, 11). Diagnosed with obliterating atherosclerosis of lower limb arteries, occlusion of the left superficial femoral artery chronic arterial insufficiency of the extremities IIB Art.

The patient underwent a left femoral-popliteal bypass with synthetic graft - signs of chronic ischemia of the lower limb regressed the index of regional systolic pressure in the left anterior and posterior tibial arteries was 110%.

In the postoperative period, the patient performed an ultrasound of the proximal and distal anastomoses on our proposed methodology. The results are presented in table 2.

0,21
Table 2.

Hemodynamic parameters proximal and distal anastomoses patient J. (Primer).
StagesIndicatorsThe proximal anastomosisThe distal anastomosis
Procs. areaDiest. area% changed.Procs. areaDiest. area% changed.
7 daysV max0,571,20+110,530,520,96+84,62
V min0,090,16+77,780,070,13+85,71
TAMH0,210,38+80,950,200,36+80,00
Pito 2.292,74+19,652,252,31+2,67
Ri0,840,87+3,570,870,86-1,15
1 monthV max0,580,94+62,070,530,74+39,62
V min0,080,13+62,500,070,10+42,86
TAMH0,220,32+45,450,29+38,10
Pi2,272,53+11.452,242,23-0,45
Ri0,860,860,000,870,86-1,15
2 monthsV max0,591,15+94,920,521,09+109,62
V min0,080,14+75,000,080,15+87,50
TAMH0,210,36+71,430,210,40+90,48
Pi2,432,81+15,642,252,10-6,67
Ri0,860,88+2,330,870,86-1,15
3 monthsV max0,571,02+78,950,530,85+60,38
V min0,070,12+71,430,070,11+57,14
TAMH0,210,33+57,140,210,33 +57,14
Pi2,382,73+14,712,192,24+2,28
Ri0,880,880,000,870,870,00
6 monthsV max0,580,99+70,670,540,87+61,11
V min0,080,13+62,500,080,12+50,00
TAMH0,220,33+50,000,220,35+59,09
Pi2,272,61+14,982,092,14+2,39
Ri0,860,87+1,160,850,86+1,18
Note: V max is the maximum linear speed;

V min - the minimum linear speed;

TMH - average linear speed;

Pi - index positively;

Ri is the resistance index.

As can be seen from the presented data, as in the first case the patient on day 7 after reconstructive intervention, apparently, there were signs of reactive inflammation AOR is anastomoses due to operative trauma to the vascular wall, this has been a temporary line narrowing of the vascular anastomosis. Proof of this is that compared to the one-month observation period hemodynamic parameters, characterizing the rate of arterial blood flow were increased by approximately 60 and 109%, respectively, in the proximal and distal anastomoses.

An interesting fact is that after the normalization in the patient investigated parameters in the first month after vascular surgery 2 months after the beginning of our study once again showing signs of narrowing of the anastomosis in the form of increased linear velocity of blood flow. It is important to note the deterioration of these indicators mainly in the distal anastomosis stenosis which, according to literature data, plays a key role in the development of rethrombosis in the postoperative period. At this stage, the dynamic observation of the increase in the rate of arterial blood flow in this area exceeded even the data obtained 7 days after reconstructive intervention (table 2). To explain these changes to the tested parameters is possible only from the standpoint of development in the area of the anastomosis proliferative process with a tendency to excessive growth neointima.

Patients received a course of non-specific immune and anti-inflammatory therapy, which led to much is the regression of the pathological changes of blood flow to 3 months and stabilize them during the entire 6-month period of our observation.

This example also illustrates the high diagnostic capabilities of our proposed method that allows dynamic monitoring of patients in the postoperative period, which contributes to the timely intervention in the treatment process and can significantly reduce the number of rethrombosis after reconstructive vascular interventions.

Thus, the proposed method of diagnosing the functional usefulness of vascular anastomosis after reconstructive surgical procedures is a highly effective, it can be used for dynamic control of surgical treatment of patients with chronic arterial insufficiency of the lower extremities. Non-invasive and easy to perform technique opens up opportunities for its use.

A method for diagnosing the functional usefulness of vascular anastomosis after reconstructive surgery on the arteries of the lower extremities, characterized in that the patient after reconstructive vascular surgery with use of Doppler ultrasound in the standard areas during the first 6 months after surgery to determine hemodynamic characteristics of blood flow proximal and distal to the vascular anastomosis and what about the change in dynamics is judged on the usefulness of vascular anastomosis.



 

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