Narrowing and occlusion of the aorta and pelvic arteries


 * The lower limbs are the most common site of arterial occlusions;
 * incidence - 6% of the population over 50, 10% over 60, 4 times more often women;
 * causes - atherosclerosi s is the main, closures in young men can cause Bürger disease ;
 * atherosclerotic changes are typically in 3 levels - aortic, femoropopliteal, crural;
 * clinical picture ;
 * isolated involvement of the aortoiliac region - claudication in the gluteal muscles;
 * complete closure of the caudal aorta - in addition impotence, lack of pulsations in the groin ( Leriche's syndrome );
 * femoropopliteal closure - calf claudication;
 * trophic changes are usually only in the case of multiple closure or crural closure (individual closures usually have collateral circulation centrally and this is sufficient to maintain viability);
 * choice of therapy - what to consider;
 * severity of the condition and degree of threat to the limb;
 * the degree of vascular involvement and the possibility of effective surgery;
 * overall condition of the patient - about 50% of patients have coronary heart disease, another 20% have damaged coronary heart disease;
 * Acute myocardial infarction is the most common cause of death after aortoiliac reconstruction;
 * we consider surgery for resting pain and trophic changes;
 * claudication - we consider the length of the claudication interval, the overall activity of the patient, his way of life…

Endarterectomy

 * It is used only rarely in the aortoillic area.

Bypass

 * Method of choice, only vascular prostheses are used;
 * most often in the form of a bifurcated aortobifemoral graft (the Y-shaped graft is found above the stenosis into the aorta and below the stenosis into the iliac);
 * the most common place of separation is from the anterior wall between the distance between the renals and the lower mesenteric (least altered part);
 * at complete closure - proximal anastomosis end to end with suturing of the caudal part of the severed aorta (simply connect the bypass directly to the aorta);
 * retroperitoneal tissues and the back of the peritoneum should always be interposed between the prosthesis and the duodenum (prevention of aortoenteral fistula);
 * aortofemoral bypass is typically performed from a long moderate laparotomy (extraperitoenal approach is also possible);
 * at one-sided pelvic artery occlusion - extraperitoneal aortofemoral or iliacofemoral bypass;
 * results - very good, operative mortality 1-2%, immediate bypass function is 95-100%.
 * results - very good, operative mortality 1-2%, immediate bypass function is 95-100%.

Extraanatomical bypasses

 * In patients with endangered limbs, when anatomical bypass cannot be established (general condition, previous surgery, infection site);
 * femorofemoral cross-over bypass ;
 * with a one-sided riverbed closure, the performance is only minimally burdensome;
 * can be performed in LA or in an epidural ;
 * axillofemoral bypass - in bilateral pelvic flow ;
 * if it is necessary to revascularize both legs - the connection between the femorals is still stretched under the subcutaneous tissue (see picture);
 * long-term function is worse, about 25% of joints require secondary thrombectomy;
 * PTA - (Percutaneous transluminal angioplasty) suitable for short stenoses of the common or external iliac, it is possible to insert a stent.

Reconstruction of the femoro-popliteal area

 * Sufficient inflow and outflow should always be verified (if there is no inflow - then proximal bypass before or simultaneously with the femoro-popliteal, or PTA, if there is no outflow - prolongation of reconstruction, lumbar sympathectomy);
 * PTA, endarterectomy, patch patch - short stenoses;
 * bypasses - femoropopliteal from the femoral artery to the upper or lower part of the popliteal artery, femoro-crural;


 * vascular prostheses (PTFE) - distal to the upper part of the poplitea (if there is sufficient drainage);
 * venous grafts - v. saphena magna, or v. cephalica, if the saphenous vein is not long enough - it is sutured distally to the lower part of the popliteal artery (there are no atherosclerotic changes - distal femoro-popliteal bypass is indicated for severe changes to the popliteal artery):
 * eversion- sewing the saphenous vein inversely (due to the flaps);
 * in situ - maintaining the normal course, but it is necessary to remove the valves with a valvulotomy;
 * composite graft - a combination of vein and vascular prosthesis;
 * special types of popliteal artery disease;
 * entrapment syndrome - anomalous course of the popliteal artery, which is pulled over the beginning of the medial gastrocnemius, stenosis and poststenotic dilatation, clinical claudication, microembolization to critical ischemia, surgical treatment ( cut the gastrocnemius medialis head or venous bypass);
 * cystic adventitial degeneration - deposition of jelly-like matter between the media and adventitia, narrows the artery and manifests itself in typical claudications, bypass treatment (venous, popliteo-popliteal)

Reconstruction of the crural area

 * it is necessary to distinguish between claudication pain (ischemic) pain and pain when the veins are affected:
 * phlebothrombosis - positive Homan's and plantar symptom, edema;
 * chronic venous insufficiency - feeling of heaviness without claudication, swelling, night cramps in the calves;
 * the most common cause (especially in men under 40, heavy smokers) is Bürger disease - it manifests itself in the development of trophic defects without a previous claudication stage and migratory phlebitis, diffuse shin artery disease is seen on angiography, treatment includes smoking cessation and prostaglandin infusions;
 * reconstructions are performed as an attempt to save the limb, preoperative angiography is necessary, according to which a place for suturing the distal end of the anastomosis is chosen, as the graft is the best v. saphena magna in situ.

Related Articles

 * Atherosclerosis
 * Artery reconstruction
 * Chronic ischemic disease of the lower limbs
 * Ischemic heart disease
 * Large vein occlusion

Source

 * PASTOR, Jan. Langenbeck's medical web page [online]. https://langenbeck.webs.com/}}
 * ws:Zúžení a uzávěry aorty a pánevních tepen