Surgical Treatment Of Arterial Occlusive Disease With Distal Single Outflow

Objective: To summarize the therapeutic effect of ASO with distal single outflow based on 20 cases(23limbs),which were performed surgical treatment in 2000 to 2008.Methods: Among the 20case(s23 limbs) of ASO, femoropopliteal artificial graft were performed in 5 limbs; profundoplasty were performed in 4 limbs; femoral-profunda femoral bypass were performed in 2 limbs; situ saphenous vein bypass were performed in 8 limbs; Balloon Injury of the distant artery were performed in 2 limbs; femoropopliteal artificial graft to single outflow artery with autograft were performed in 2 limbs; adopt arterial of the deep vein were performed in 2 limbs.Results: 1.Short term result: In 20cases, no 1 case died in perioperative period. In 1case, cerebral infraction were complicated in perioperative period, But transplanted vessel maintains unobstructed. Until discharged, Transplanted vessels in 19 limbs were still unobstructed. In 17 limbs,ischemic symptom were alleviated evidently after operation, Postoperative ABI was 0.79~0.92, which had the visible difference(p <0.01). And postoperative shell temperature of affected limb showed ascending trend. 2 limbs which concurrent ulcer were allleviated. 3 days after operation, the ischemic symptom of 3 limbs were recurrenced. 1case was which underwent situ saphenous vein arterial bypass,1case was which underwent venous arterialization , And 1case was which underwent profundoplasty。And 2 caess of them the ischemic symptom were aggravated. And after operation in 1case the symptom were alleviated which were performed situ saphenous vein arterial bypass. But because of severe ischemia,in 1 case amputation were performed. Duraing operation we detected thrombosis in graft and anastomotic stoma.2.Follow up result: In 20 cases, 18 cases were followed up for 5 months to 5 years. Chronic graft obliterance happened in 2 limbs(8.7%), 1 case of them which performed situ saphenous vein arterial bypass, But in this case didn't appeared obvious ischemic symptom. Another case which performed femoroprofundus artificial graft. when after medical treatment, ischemic symptom were allleviated。Other 17 cases(except 1 case which were performed amputation), 15 cases rest pain were disappeared, And ulcer in 2 limbs were healed up in 1 year. Conclusion: Beforetime, We consider underdelelopment of outflow during angiography as contraindication. But we realized that if one artery in calf remains unobstructed, we can prevent limbs from amputation. We consider that hereinafter ingredient may contribute to ameliorate blood circulation in single outflow limbs.1.Arterial net around knee joint: There is abundance blood circulation around knee joint. And comprised of popliteal artery,femoral artery,tibialis anterior,terminal branch of tibialis posterior, communicating branch and anastomotic net. When popliteal artery obstruted, this arterial net plays an important role. When stenosis or obliterance in fibular artery or tibialis anterior, recurrens tibialis anterior can establish collateral circulation. This arterial net is academic foundation of surgical treatment in single outflow limbs. We relized that when femoropopliteal artery obstructed, Artirial supply of distal tissues mainly from around knee joint collateral circulation.2.Profunda femoris: Profunda femoris is the biggest branch in femoral artery. Plays an important role in arterial supply. Because ASO always can't come down to profunda femoris, we can perform reconstitution proximal end. Collateral branch in femoral artery- profunda femoris-tibial artery provides outflow. Profundoplasty involves endarterectomy and repair of incisional hernia. And can reserve limbs or prolong distance of Intermittent claudication.3.Anastomosis of pedal blood vessel: Pedal outflow not noly short but also fewness. So we ameliorate pedal outflow when performing bypass. Some report shows after pedal bypass, it's unobstruct rate approaches 70% in 2 years. But at the same time this kind of operation not only comparatively but also the failure rate is high. To ensure long term unobstructing, can also add distal arteriovenous fistula.4 .Outflow of ankle: The single outflow of ASO often involves stricture or obstruction of two or more distal artery. Thus bypass graft distal from the knee is necessary. And the best choice is tibialis posterior. For its position is near great saphenous vein. And the duct of great saphenous vein is suited to the one of distal artery, therefore it needn't strip extensively. Low damage and high patency are the main advantage in site saphenous vein artery bypass. In addition, great saphenous vein is ideal graft material for its physiological activity and ability to anti-thrombosis.When the outflow distal from knee are all obstructed, it may choose venous arterialization. It may lower amputation level visibly and salvage the limb. Venous arterialization is mainly used in patients without outflow.5. Endo-vascular therapy: Since operation of single distal outflow is complicated relatively, and the patients often have chrinic disease such as hypertension, coronary heart disease, cerebral disease or chronic renal failure etal. Because of high operation risk and ill-condition of vessel. Approximately, 37 % of patients whose distal artery are obstructied are not adaptive to perform bypass graft. By utilizing IGPTA technique, the three year limb salvage rate approaches 77 % - 89 %.