Abdominal aortic and iliac artery endarterectomy

Abdominal aorta and radial artery endarterectomy are used for the treatment of abdominal aorta and chronic occlusion of major branches. Abdominal aorta and radial artery stenosis are not as common in China as in Western countries, and they are still one of the common diseases in vascular surgery. The majority of this disease is caused by atherosclerosis, and the range of involvement is regular. It is most common in the lower aortic segment of the abdominal aorta, involving the bilateral common iliac artery and the internal iliac artery. The external iliac artery is less affected or only The initial segment is involved within 1 to 2 cm. However, the disease is often progressive, can cause occlusion near the abdominal aortic bifurcation, but also can spread distally to the external iliac artery, the common femoral artery and the superficial femoral artery or even the iliac artery, leaving only the deep femoral artery as the lower limb. Supply blood vessels. Fortunately, the upper end of the inferior segment of the abdominal aorta, that is, near the renal artery, is rarely involved, so that reconstruction surgery can be completed in an easily revealed range. Abdominal aortic angiography is the most reliable qualitative and localized diagnostic method. There are two main surgical methods: endarterectomy and vascular bridging. Both procedures have advantages and disadvantages. Endometrial ablation can be accomplished by extraperitoneal route, relatively safe, with fewer complications, no foreign bodies, and less susceptible to infection, but only for those with relatively limited lesions, and the operation time is longer, and the large free blood vessels lose more blood. Big. Vascular bridging requires abdominal or extraperitoneal application, the vascular free range is small, the operation is relatively simple, the operation time is short, and it is not restricted by the scope of the lesion, but there are foreign bodies left, and infection may occur. Because the disease has a tendency to progress, sometimes the endometrial exfoliation can not prevent the spread of the lesion to the distal end, affecting the long-term effect, so in recent years, more bridging is used, and endometrial ablation is less. If the severe stenosis of the abdominal aorta is close to complete occlusion, but is ill or in an emergency, extra-anatomic bypass, such as the radial artery-femoral artery bridge and the femoral-femoral artery, is sometimes required. Bridge surgery. Treatment of diseases: abdominal aortic coarctation Indication Applicable to the relative limitation of arterial stenosis, that is, limited to the lower aortic segment of the abdominal aorta, the abdominal aortic bifurcation, the common iliac artery, the internal iliac artery, and the external iliac artery is basically intact. This procedure is also feasible in patients with calcification of the arterial wall. Contraindications Endometrial ablation should not be performed in patients with limited expansion of the abdominal aorta (bulging or thickening). Dilation is a manifestation of degenerative changes in the arterial membrane. At this time, if the intima is removed, the formation of a pseudoaneurysm will be accelerated. Preoperative preparation 1. Prepare the skin from the xiphoid to the lower third of the thigh. Because of the possibility of changing the plan during surgery, the aortic-femoral artery bridging technique is changed. 2. Prophylactic use of antibiotics. Surgical procedure Incision For patients with limited lesions, the left oblique extra-abdominal oblique incision was performed from the left 12th rib tip to the 5-7 cm midline under the umbilicus. After the anterior sheath of the rectus abdominis is opened, the rectus abdominis muscle is pulled to the midline, and if necessary, it can be partially cut off, and the external oblique muscle, the intra-abdominal oblique muscle and the transverse abdominis muscle are excised layer by layer to reveal the peritoneum. Push the peritoneum together with the descending colon and sigmoid colon to the inside and enter the retroperitoneal space. The blunt dissection of the midline was continued along the anterior border of the psoas muscle. The abdominal viscera was covered with a gauze pad and then pulled to the right side to expose the abdominal aorta and the bilateral common iliac artery. If necessary, the inferior mesenteric artery can be severed to increase exposure. If the lesion is more extensive, a median transabdominal incision is still needed. Free Carefully free the abdominal aorta and bilateral common iliac artery, external iliac artery and internal iliac artery, in order to exceed the lesion range of 2 ~ 3cm, while releasing the recommended middle artery and the corresponding plane of the lumbar artery and control. 3. Arterial incision The vascular occlusion forceps were used to control the abdominal aorta and the bilateral internal and external iliac artery to cut into the vascular lumen along the anterior wall of the diseased vessel. The incision should extend beyond the extent of the lesion to clearly reveal the intima to be left behind. The sympathetic plexus, which plays an important role in maintaining male sexual function, is located on the left side of the bifurcation of the abdominal aorta and should be carefully protected. To this end, the vascular incision should be made to the left and right, avoiding the "human" shaped incision. 4. Endometrial exfoliation Accurately find the subendocardial space of the artery, and use the endometrial stripper or blunt-bend tissue to cut the full-circumferential peel of the endometrium. Continue to peel up and down until the end of the lesion's intima, where the intima becomes thinner and adheres tightly to the media. First cut the endometrium at the upper end, then check if the distal peeling is sufficient, and then cut it off after confirming it. 5. Distal endometrial fixation Rinse the lumen of the vessel with heparin saline (heparin 5000 U/100 ml) and check for free floating inner membrane at the distal end. If so, carefully trim it. The 6-0 single-strand non-absorbent line was used to suture the intimal edge and the vessel wall, and the knot was facing outward. 6. Arterial suture The blood vessels were continuously sutured with a 4-0 or 5-0 single-strand non-absorbent line. Before the lower end of the incision is tightened and ligated, the distal and proximal vascular blocking forceps are instantaneously opened to rush out debris or blood clots that may remain. After the ligation is completed, open the distal blocking forceps to check for blood leakage and break the needle if necessary. Open the proximal blocking forceps again. Press the saline pad for a while to stop the small blood leak. 7. Arterial patch If the lumen is still thin after the endometrial ablation, a polyester or polytetrafluoroethylene (PTFE) patch (one or two) may be added to enlarge the caliber. 8. The wound surface is completely hemostasis. After washing and absorbing, the incision is sutured layer by layer. Do not let the drainage. complication 1. Arterial suture bleeding. 2. Intra-arterial thrombosis. 3. Lower extremity arterial embolization. 4. Aortic plexus injury causes male sexual dysfunction. However, it is necessary to distinguish from impotence caused by insufficient blood supply to the inferior epigastric artery caused by arterial stenosis or occlusion. The latter has sexual dysfunction before surgery.