Surgical Treatment Of Arterial Occlusive Disease In The Lower Extremity

Arterial Occlusive Disease of Low Extremity ( ASO) encompasses a range of chronic occlusive arterial disease caused by atherosclerosis in low extremity artery. Atherosclerosis is a complex pathological progression to which several factors contribute. Although its etiology remains unclear, several theories have been proposed to explain the process of developing atherosclerosis. 1. initial injury. 2.lipid ingiltration. 3. SMC(smooth muscle cell) proliferation. The infrarenal abdominal aorta, the iliac arteries and femoral artery are among the most common sites of chronic obliterative atherosclerosis.According to the literature report and the epidemiology research, the risk factor of atherosclerosis include: cigarret smoking, diabets, dyslipidimia, hypertension, lack of physical exercise, emotional tension, genetic factor, age and sex. The structure and function of arterial wall and the hemodynamic also contribute to development of atherosclerosis.The clinical manifestation include pain , numbness, coldness in low extremity, intermittent claudication, loss of aterial pulse, atrophy of limb, ulceration and gangrene of toe and foot. The patient are classified by the clinical presentation. Stage I: minor complains. Stage II: intermitent claudication. Stage III: resting pain. Stage IV: ulceration and gangrene.In most instances, an accurate history and a carefully performed physical examination can establish the diagnosis of ASO. Some special invasitive techniques allow objective physiologic quantification of severity of the disease process.1,Ankle-Brachial Indices (ABI): A quick and cost-effective way to establish or refute the ASO diagnosis. The normal value of ABI is more than 1.0. The ABI less than 0.8 means ischemia of low limb. The ABI less than 0.5 means severe ischemia of low limb.2,Duplex ultrasoun: can provide the accurate information about the arterial anatomy and hemodynamic.3,Magnetic Resonance angiography(MRA): is noninvasive and not fit for calcificated artery. The patient extremly weak , high risk , with renal dyfunction and allergic to contrast medium can benefit from MRA.4,DSA: the golden standard for the diagnosis of ASO. The extent and the distribution of disease, as well as the collateral circulation can be deliminated. A complete anatomic assessment of the affected arterial territory including imaging of occlusive lesion as well as arterial inflow and outflow can be deliminated.The Stage III or IV ASO is the absolute indication of operation. Most of these patients will lose their limbs, if not treated promptly. Age is rarely an absolute contraindication. Even patients who are elderly or frail or for whom surgery poses high risks because of multiple associated medical problems generally can undergo revascularization with alternative surgical methods. Intermittent claudication is relative indication of operation. For these patients, Oprative decisions must be indivualized, with each patient s age, associated medical disease, employment requirement and lifestyle preferences taken into consideration. Claudication that jeopardizes the patient s livelihood or significantly impairs the desired lifestyle and daily activeties of a patient for whom surgery would be a low risk may be considered to be a reasonable indication for surgical correction if the anatomic situation is favorable for intervention. For the Stage III and IV ASO patients whose general condition can endure operation, if the properate operative procedure are chosen according to the situation of arterial inflow and outflow assessed by MRA or/and Duplex ultrasound, the results of operation are satisfactory.This dissertation summarized the recent ten-year literature on surgical treatment of ASO, generalized the operative technique, operative results and follow-ups. There were also reports of femoropopliteal bypass on 51 cases of ASO (53 limbs) in our deparment in the dissertation. The graft, the operative technique and the management of operative and postoperative complications were discussed.Method: Among the 51 cases of ASO, 33 underwent femoropopliteal prosthetic bypass, 11 underwent femoroprofunda prothetic bypass, 7 underwent in situ saphenous vein bypass. The results of operation were assessed by clinical symptom, ABI and Duplex ultrasound.Results: The ischemic symptom were alleviate immediately after operation in all patients. The follow-up varied from 6 month to 2 years. The average follow-up was 1.5 years. 5 cases suffered ischemic symptom again, The ischemic symptom were alleviated after medicine treatment in 3 cases. The other 2 cases were amputated. The prosthetic patency was 88% and 96% of the limb were reserved.Conclusion: The ASO patients in Stage III or IV are in advaced age and have severe complication. Severe intermittent claudication, resting pain, ischemic unlcer and gangrene not only jeopardize their limbs, but also their lives. Severe resting pain, ulceration in foot and ischemic gangrene mean limb losing without active intervene. The purpose of opertion is to save the limb. For the Stage III and IV ASO patients whose general condition can endure operation, the proper operative procedure should be chosen according to the situation of arterial inflow and outflow assessed by MRA or/and Duplex ultrasound to save the limb and improve the living quality.