| ObjectiveThere are about 200 million ASO patients in the world,more than half of them are femoral popliteal artery and inferior genicular artery occlusion,however,most of the lesions in diabetes and elderly patients are below popliteal artery.Endovascular treatment and bypass surgery are the most common methods for the treatment of femoral popliteal artery lesions.However,for severe CTO lesions,the premise of endovascular treatment and bypass surgery is to have an appropriate outflow tract under the knee.The construction of outflow tract is an urgent problem in the surgical treatment of patients with TASC D classification.The sural artery is a pair of branches from the popliteal artery,which supplies the blood supply to the calf gastrocnemius muscle.In our previous work,we found that at the end stage of arteriosclerosis in the lower extremity,the main artery was occluded,while the sural artery maintained a high patency.In the first part of this experiment,the position and course of the sural artery,the diameter and blood flow parameters in the main vessels below the knee and the sural artery in the normal group and the lower extremity arteriosclerosis group were studied by ultrasound;In the second part,we studied the pathological morphology of popliteal artery,main artery below popliteal artery and sural artery,the collateral circulation of knee joint and calf muscles through the anatomy of amputated specimens;In the third part,we studied the clinical efficacy of sural artery in helping CLI patients with TASC D grade to establish the outflow tract during femoral popliteal artery bypass surgery.MethodsPart Ⅰ:A total of 50 young patients(aged 30-50 years old,median age 43.5 years old)were collected.Ultrasound examination of lower extremity vessels excluded lower extremity arteriosclerosis.60 patients with lower limb arteriosclerosis occlusion disorder,age range 50-82,the median age of 69.3 years,according to the regulations of installment method will Ⅰ Fontaine,Ⅱ period for mild atherosclerosis,type Ⅰ;Ⅲperiod for mild atherosclerosis,type 2;Ⅳ period for severe atherosclerosis,type Ⅲ.The lower extremity vessels were examined by ultrasound.The location,shape,diameter,pairing and blood flow parameters of the sural artery,the diameter and blood flow parameters of the anterior tibial artery and posterior tibial artery,and the pathological classification of the sural artery were observed in the normal group and the arteriosclerosis obliterans group by ultrasound.Part Ⅱ:Collect fresh amputation samples of lower limb ischemia,drain venous blood from the limbs,insert 9 scalp needle into the femoral artery at the amputation plane,and rinse repeatedly with heparin water.After successful perfusion,formalin was soaked and airdried.The air-dried specimens were dissected to observe the pathological changes and morphology of the main artery and branch artery below the knee,as well as the collateral circulation around the knee joint and the calf muscle.Part Ⅲ:30 TASC grade D patients with severe lower extremity ischemia received femoral-superior geniteal popliteal artery bypass+popliteal artery sural arterioplasty for failure of intracavitary opening,occlusion after stent implantation,and subgenital outflow tract score below 1 point.There were 24 males and 6 females,the age range ranged from 62 to 87 years old,with an average age of(72.6±10.9).Perioperative clinical efficacy,complications,primary and secondary patency rate,limb salvage rate and postoperative changes of sural artery were observed.ResultsPart Ⅰ:We found that the detection rate of the sural artery was high and the shape was constant through the ultrasound study of the sural artery in the normal group and the lower extremity arteriosclerosis group.In the arteriosclerosis group,there were three types of sural artery:complete patency,proximal stenosis and total occlusion.The overall patency rate was 91.7%.In the normal group,the T value of the maximum flow velocity in systolic period,the maximum forward flow velocity in diastolic period and the average flow velocity of the sural artery,the anterior tibial artery and the posterior tibial artery were 0.311,1.513 and 0.157,respectively,and the P value was 0.756,0.133 and 0.876,respectively,without statistical difference(P>0.05).Type Ⅰ,Ⅱ mean velocity of lower limb arteriosclerosis sural artery Vmean pretibial artery,posterior tibial artery and the average velocity of Vmean compare F value 0.123,0.057,respectively,P values were 0.885,0.945,is no statistical difference(P>0.05),type Ⅲ mean velocity of lower limb arteriosclerosis sural artery Vmean and former tibial artery,posterior tibial artery average flow velocity,F=3.336,P=0.043,statistically significant differences(P<0.05).The normal flow of sural artery was 63.1%of anterior tibial artery and 69.1%of posterior tibial artery.In the lower extremity arteriosclerosis group,the flow ratio of the sural artery to the anterior tibial artery and the posterior tibial artery was 60.1%and 68.7%,respectively,and that of the sural artery to the posterior tibial artery was 65.2%and 68.1%,respectively,in the patients with type Ⅰ and Ⅱ lower extremity arteriosclerosis.In patients with type Ⅲ lower extremity arteriosclerosis occlusion,the flow ratio of sural artery,anterior tibial artery and posterior tibial artery were 114.1%and 133.3%,respectively.Part Ⅱ:Through the anatomical study of amputated specimens,it is found that the occlusion of infrapopliteal artery is mainly caused by plaque formation and secondary thrombosis,vascular occlusion had serious adhesion around,expansion and separation prone to arteriovenous fistula.The main articular branches of popliteal artery are superior and inferior genicular arteries,which supply the skin and soft tissue around the joint.The main muscular branch of popliteal artery is sural artery,and the pathological types are long segment occlusion,stenosis at the opening and complete patency.In 11 amputation specimens,the proportion of long segment occlusion was 18.2%(2/11),the opening of vascular was narrow or occlusion,the proportion of the distal segment was patency was 27.3%(3/11),and the proportion of the main artery was completely patency was 6 cases(54.5%,6/11).The most clinically significant manifestations were the second and third types,and the vast majority of collateral vessels in this group were manifested in the second and third types,accounting for 81.8%(9/11).There are abundant collateral circulation in leg muscle in patients with Infragenual main artery occlusion.Part Ⅲ:The success rate of operation was 100%.After operation,3 cases were obviously effective,23 cases were effective,4 cases were ineffective and 2 cases deteriorated.The improvement rate of clinical symptoms was 26/32(81.3%).The primary patency rate was 88.9%,81.5%,63.0%and 44.4%,the secondary patency rate was 92.6%,85.2%,70.4%and 51.9%,and the limb salvage rate was 78.1%,71.8%,62.5%and 50.0%,respectively at 3,6,12 and 24 months.Postoperative compensatory dilatation of sural artery as outflow tract was found in 18 cases.The distal anastomotic site is at the sural artery and the occlusion of artificial blood vessel is easy to lead to branch occlusion.ConclusionThe position of bilateral sural artery is constant and the blood flow is large,especiall when the main inferior genicular artery is occluded in ASO patients,the proportion of sural artery flow was higher than that of anterior tibial artery and posterior tibial artery.The pathological types of gastrocnemial artery in ASO patients were mainly long segment occlusion,stenosis at the opening and complete patency,the latter two are the majority.In patients with end-stage cli,sural angioplasty can be used to make up for the shortage of outflow tract.When the outflow tract of patients in TASC D grade was poor,use sural artery plasty to make up for the absence of outflow tract in femoral popliteal artery bypass surgery can provide higher primary and secondary patency rate and limb salvage rate,at 12 months and 24 months,they were 63.0%,44.4%,70.4,51.9%,62.5%,50.0%,respectively,it is worthy of clinical application and promotion. |
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