| OverviewTrauma of large vessel close to the neck and trunk is very common both in war condition and traffic accident,the bleedings due to the trauma are fierce and life-threatening. Most of the patients can not be treated in time and are often complicated by hemorrhagic shock and death. Traditional cassette and cuff tourniquet can only be used to stop bleeding of extremity vascular injuries, together with the venous flow blocking, likely to cause limb congestion, thrombosis. In1987, one patient of the right axillary artery giant pseudoaneurysm came to our department, during the operation,because of the uncontroble bleeding and edema,the only way to save the patient’life seemed to truncate the patient’right arm. Professor Ma Lianting creatively using the balloon catheter to temporarily block the arteries of blood flow,the operation succeeded,the arm survived. Using this tecknolege,we treated34cases of adjacent large blood vessels of the neck and trunk injury successfully.Then we invented a application,in the emergency situation, needing no X-ray fluoroscopy,we can puncture the vessel and fill the balloon to block blood flow.we name the application "intravascular tourniquet".To study its safe clamping time and pressure parameters, we have rabbits for experimental studies;we also analyzed previous treatment of34cases of large vessels close to the neck and trunk damage and its late complications of pseudo-aneurysm and arteriovenous fistula and the results were analyzed retrospectively.Part I The Design and use of "intravascular tourniquet "we design a standard product and name it " intravascular tourniquet ", Hunan Ai Pute medical Devices Co., Ltd produce the product.Its design is similar to the clinical application of the catheter sheath, consists of four parts:①outer sheath13cm long, front-end, flat head, the end with elastic valve diameter6F;②The sheath:length14cm, diameter of4F, the cavity can be0.035-0.038guidewire;③guide wire:length40cm, diameter0.035-0.038, the front-end is straight;④The ball capsule sheath:length16cm, diameter of4F, front-end blind side, away from the line side13.5cm,at side wall to open a small hole to install a2cm long from the front-end0.5cm at filling in diameter,6mm balloon.2. The use of intravascular tourniquet"Using the Seldinger method to puncture the artery,within the sheath tube inserting into the outer sheath, then exit the sheath, the sheath from the outside into the ball capsule sheath. And then filling the balloon until the arterial bleeding is stopped. After the use, emptying the balloon, the balloon revenue outer sheath, then the inside sheath and the outside sheath was pulled out.Part Ⅱ The invention of internal tourniquet and its experimental studiesObjective To Develope a self-made " vascular tourniquet", with animal experiments to investigate t its safe clamping time and pressure parameters.Methods(1) Intravascular placement of the tourniquet after the success of anesthesia, the right common carotid artery using the Seldinger method retrograde inserted6F " vascular tourniquet", remove the sheath, into the4F imaging cholangiography, have a road map, insert the ball capsule sheath into the vessel lumen, and then inject180mg/ml nonionic contrast medium the0.15ml contrast agent (1atm) filled balloon with balloon end of the balloon, angiography confirmed occlusion of blood vessels, recorde time and the determination of the pressure within the balloon,use the Philips M1567A pressure sensor transducer to measure balloon pressure.(2) Animal grouping40rabbits were randomly divided into four groups:group A,16,"vascular tourniquet " continuing to block the right common carotid artery1h; further divided into A1, A2, A3, A4-group (n=4) respectively, lh,5d,14d21days after the placement of intravascular tourniquet ", take the right common carotid artery arterial blood5ml to check ET concentration; the right common carotid artery is divided into three sections specimens were sent for electron microscopy and immunohistochemistry (HIF-1, caspase-3, by TUNEL), vascular tissue homogenates by ELISA examination (HIF-1and caspase-3), RT-PCR, and WB check (NF-KB).In group B,16, intravascular tourniquet continued to block the right common carotid artery2h; further divided into B1, B2, B3, B4, group (n=4), respectively,the examination is the same as group A. Group C, the blank control group,4,1h after anesthesia," intravascular tourniquet" is not placed in the right carotid artery, the examination is the same as group A. Group D, sham operation group4, exposed to the right common carotid artery for1h, the examination ist he same as group AResults 1. Immunohistochemical staining:1.1HIF-1results:HIF-1positive cells of group A (mild vascular injury group, the "vascular tourniquet " closed1h group) compared with the normal group:HIF-1number of positive cells reached a peak (p<0.01)1h after surgery, coloring deeply; HIF-1positive cell number after5d are still more, coloring lighter (p <0.05); HIF-1positive cell after14d returne to normal (p>0.05); HIF-1-positive cell remained normal levels (p>0.05)after21d. Group B (severe vascular injury group, the vascular tourniquet " closed2h) HIF-1positive cells in compared with the normal group:HIF-1positive cell number reduce significantly or (p>0.05) after1h, but coloring darker; HIF-1positive cells reached a peak after5d, coloring lighter (p<0.01); HIF-1-positive cells returned to normal (p<0.05) after14d; HIF-1-positive cells remained normal levels (p>0.05) after21d. the number of positive cells in sham operation group,compared with normal group, no significant difference (p>0.05)(Table2.1, Figure2.1-2.10).The positive cells in severe injury group compared with mild injury group respectively:group B1more than in group A1(p<0.01); group B2more than in group A2(p<0.01), group B3more than in group A3(p<0.05); positive cells in the A4group had no significant difference with B4.(p>0.05).These results indicate that:the number of positive cells of HIF-1after lh reached the peak,14d after returned to normal;21d after remain normal. The number of positive cells of HIF-1in severe injury group compared with mild injury group of HIF-1positive cells had significant difference.1.2Caspase-3results:Caspase-3positive cells of group A (mild vascular injury group, the "vascular tourniquet " closed lh group) compared with the normal group group:the number of Caspase-3positive cell after1h had no significantly difference (p>0.05), but coloring shallow; Caspase-3positive cell number increased significantly after5d, coloring darker (p<0.01); Caspase-3positive cells reached the peak14d after14d,coloring darker (p<0.01); Caspase-3positive cells remained at high level after21d (p<0.01). Caspase-3positive cells of group B (sever vascular injury group, the "vascular tourniquet " closed2h group) compared with the normal group group:the number of Caspase-3-positive cell after1h had no significantly difference (p>0.05), but coloring shallow; caspase-3positive cell number increased significantly after5d,coloring darker (p<0.01); caspase-3positive cells reached the peak after14d, coloring darker (p<0.01The); Caspase-3positive cell number remained at high level after21d (p<0.01). positive cells in the Sham operation group had no significant difference with the normal group (p>0.05)(see Table2-2, Figure2.11-2.20).The positive cells in severe injury group compared with mild injury group respectively:the number of positive cells had no significant defference after1h (p>0.05); positive cells of group B2was more than group of group A2(p<0.01), positive cells of group B3was more than group of group A3(p<0.01); positive cells of group B4was more than that of group A4(p<0.01).These results indicate that:the number of positive cells of Caspase-3after5d increased, reached the peak after14d,remained at a high level after21d; The number of positive cells of Caspase-3in severe injury group compared with mild injury group of Caspase-3positive cells had significant difference.2. ELISA results2.1HIF-1results:mild vascular injury group ("vascular tourniquet closed1h group) of HIF-1levels compared with the normal group:HIF-1concentration reached a peak after lh (p<0.01); HIF-1concentration was still higher after5d (p<0.01); HIF-1levels return to normal after14d (p>0.05); HIF-1levels remained normal levels after21d (p>0.05). HIF-1levels of severe vascular injury group compared with the normal group:HIF-1concentration reached a peak the postoperative1h (p<0.01); HIF-1levels are still high group after5d (p<0.01); HIF-1concentration is still higher after14d (p<0.05); HIF-1levels returned to normal levels after21d (p>0.05). HIF-1levels of sham operation group compared with the normal group had no significant difference (see Table2.3).HIF-1levels of severe injury group compared with mild injury group respectively,:B1group was significantly higher than in group A1concentration,(p <0.01); group B2had no significant difference compared with group A2(p>0.05); group B3had no significant difference compared with the A3group (p>0.05) group B4had no significant difference with group A4(p>0.05).These results indicate that:HIF-1levels reached a peak after1h, return to normal after14d; HIF-1levels of severe injury group compared with mild injury group had significant difference.2.2caspase-3results:caspase-3levels of mild vascular injury group ("vascular tourniquet closed1h group) compared to caspase-3levels of the normal group Caspase-3levels had no significant after1h (p>0.05); Caspase-3concentration was significantly higher after5d (p<0.01); caspase-3concentration reached its peak after14d (p<0.01); Caspase-3concentration began to decline after21d, is still at a high level (p<0.05). Caspase-3concentrations of severe vascular injury group ("vascular tourniquet closed2h group) compared with the normal group Caspase-3concentrations after1h had no significant differrence (p>0.05); caspase-3concentration was significantly higher after5d (p<0.01); caspase-3concentration reached a peak after14d (p<0.01); caspase-3concentration remained at high level after21d (p<0.01). Sham operation group compared with the normal group had no significant difference (p>0.05)(Table2.4) Caspase-3concentrations of severe injury group compared with mild injury group: B1group compared with the concentration of A1group had no significant difference (p>0.05); B2group compared with the concentration of A2group had no significant difference (p>0.05), B3group compared with the concentration of A3group had no significant difference (p>0.05); group B4had significant difference with A4(p<0.01).These results indicate that:Caspase-3concentrations increased after5d, r reached the peak afte14d, remained at a high level after21d; Caspase-3levels of severe injury group compared with mild injury group had significant difference.3.Western-Blot Results.Mild vascular injury group ("vascular tourniquet occlusion lh) NF-KB increased1h,protein reached the peak at5d,14d began to decline, but remained at a high level remained at a high level,21d; severe vascular injury (tourniquet intravascular occlusion2h) NF-KB increased1h protein was significantly higher,5d,14d and reached the peak,21d remained at a high level. sham operation group NF-KB with the normal group had no significant difference (see Table2.5, Figure2.21). NF-KB of severe injury group compared with mild injury group::B1group had no significant difference compared with group A1; group B2increased than the A2group; group B3was higher than group A3;,group B4was still higher than than group A4. These results indicate that:NF-KB increased after1h, reached the peak at5d,14d and21d are still at a high level; the sever injury group compared with its time of mild injury group, the severe injury group caused a strong NF-KB expression while a lesser extent of damage caused by the expression level is weak.4.RT-PCR resultsMild vascular injury group ("vascular tourniquet occlusion1h)1h after protein increase, reached a peak5d,14d began to decline, but remained at a high level remained at a high level,21d; NF-KBmRNA in severe vascular damage group (intravascular tourniquet occlusion2h) increased after1h, reached the peak at5d,14d began to decline,21days remained at a high level. Sham group and normal group had no significant differrence (see Table2.6, Figure2.22). NF KBmRNA of sever injury group compared with its time of mild injury group:B1group is higher than in group A1; A2group increased than in group B2; B3groups higher than the A3group; B4group had no significant differences with A4.These results indicate that:vascular tourniquet placed in the postoperative NF-KBmRNA increased after1h,reached the peak at5d,14d and21d at a high level; vascular tourniquet" implantation of severe injury group caused a strong NF-KBmRNA of expression, the expression level of the lesser extent of damage caused by the weaker.5.TUNEL staining resultsMild vascular injury group ("vascular tourniquet " closed1h group) of number of apoptotic cells compared with normal group:After1h, apoptotic cells had no significant increase or decrease (p>0.05), but the colore is shallow;5d increased significantly, coloring darker (p<0.01);14d apoptotic cells at the height,coloring darker (p<0.01); postoperative21d positive apoptotic cell count began to decline, but remained at a high level (p<0.01). Severe vascular injury group ("vascular tourniquet" closed2h group) of apoptotic cells compared with normal group:after1h apoptotic cells had no significant difference (p>0.05), the coloring lighter;5d apoptotic positive cells were increased, the coloration darker (p<0.01); after14d positive apoptotic cell count is still at its peak, the coloration darker (p<0.01);21d positive cells began to decline, but remained at a high level (p<0.01). The number of positive cells in Sham operation group compared with normal group had no significant difference (p>0.05)(see Table2.7, Figure2.23-2.32). The severe injuries of the apoptosis number of positive cells compared with its time of mild injury group:the number of apoptotic cells in B1group had no significant difference (p>0.05); B2group was more than those in group A2(p<0.05); B3group of apoptosis-positive cell hda no significant difference with the A3group (p>0.05); B4had no significant difference with group A4(p>0.05).These results indicate that:the number of postoperative positive apoptotic cells increased after5d,14d reached the peak,21d remained at a high level; severe injury group of apoptotic cells had significant difference compared with its time of mild injury group.6. ET resultsET concentration in Mild vascular injury group ("vascular tourniquet " the closed lh group) compared with the normal group:after1h ET concentration was significantly higher (p<0.01), reached a peak;5d ET began to decline, but is still higher than high (p<0.05);14d ET concentrations returned to normal (p>0.05);21d ET concentration remained normal levels (p>0.05). ET concentration in Severe vascular injury group ("vascular tourniquet " the closed1h group) compared with the normal group:after1h ET concentration was significantly increased and reached the peak (p<0.01);5d ET is still significantly higher (p <0.01).;14d ET concentrations returned to normal (p>0.05);21d ET concentration remained normal levels (p>0.05). Sham operation group had no significant difference with the normal group (p>0.05)(Table2.8).ET concentration of severe injury group compared with mild injury group:B1group concentration was significantly higher than in group Al, there are significant differences (p<0.05); significantly higher in group B2than the A2group (p <0.05); B3group had no significant difference with group A3(p>0.05); B4, group had no difference with A4group (p>0.05). These results indicate that:postoperative1h ET concentration reached a peak postoperative14d ET back to normal; at the same time segment severe injury group compared to the mild injury group, ET concentration is higher than the mild injury group.7. electron microscope results:In normal control group or the sham operation group, elastic coating the inside of the thin layer of endothelial cells within the normal artery, the outer ring layer of longitudinally arranged smooth muscle cells, smooth muscle cells of filaments. After1h, the group A blood vessel wall did not change, straighten the internal elastic membrane and smooth muscle cells in group B.5d, the group A of the intima and middle edema and inflammatory cell infiltration; group B In addition, see the part of the internal elastic membrane fracture associated with the outer layer of point-like bleeding, increased smooth muscle cell density.14d, A group of inflammatory edema disappeared, endometrial mild thickening of the presence of internal elastic membrane, outer smooth muscle cells and collagen fibers; group B, see subintimal fibrosis, fibroblast endoplasmic reticulum expansion.21d, group A wall returned to normal; Group B intimal smooth, the lower thickened intima containing fibroblasts (Figure2.33-2.42).8.All animals in vivo experimental results:all animals was alive, had no wound infection and symptoms of cerebral ischemia.9. Visual observation of the arterial wall:remove the balloon, only four arteries in the B1group after1h are still mild expansion, the rest were patency, neointimal smooth and complete. no thrombosis.10. Injecting the0.15ml contrast agent (1atm) to the balloon can block the arteries of blood flow.11. Pressure in the balloon was was20.4±1.1kPa, the arteries wae35.5±3.1kPa ranging.Conclusions1. The expression of cytokines was the time vary:After1h, the HIF-1, ET expression were increased, Caspase-3, NF-KB, and TUNEL-positive cells increased after5d, indicating that HIF-1^ET was first activated, which can then activate the control of apoptosis genes, such as Caspase-3, NF-KB expression, thereby causing apoptosis.2.5d-14d period after the "vascular tourniquet" implantation is a critical period for determining the vascular injury outcome.3. The degree of vascular injury correlated with apoptosis.4. It is a safe and effective of pressure and time parameters to injecte into the vascular tourniquet balloon the0.15ml contrast agent (1atm), continuous blocking to no more than2h, and cause only mild changes of the arterial wall structure, reversible2-3weeks to return to normal. But the longer the clamping time, the greater the impact on the wall. Part III:Feasibility of transarterial blood flow oclussion by internal tourniquet to decrease blood loss on the cases of arterial injuriy to the trunkObjective To study the feasibility of transarterial blood flow oclussion by internal tourniquet to decrease blood loss on the cases of arterial injuriy to the trunk.Methods From May1987to February2001,35cases of arterial injuries near trunk were treated by repair of the blood vessel after temporary occlusion of blood flow with internal tourniquet. The blocking time were40to70mins each with an interval of15to20mins. Results After transarterial blood flow occlusion with internal tourniquet,there was much less intraoperative hemorrhage(the amount of bleeding was low to400ml),the operating field was clean and the anatomic structures were exposed clearly.All the patients had been cured,No relapse and ischemia of brain and limbs appeared during3to14years follow up. Conclusion In the treatment of the arterial injuries closed to the trunk, Occlusion of major blood supply arteries with internal tourniquet can effectively reduce operative hemorrhage,it can promote the safety of the operation. |
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