Transabdominal approach for thrombectomy at the bifurcation of the abdominal aorta

Thromboembolism in the main arteries of the extremities, except for some parts (such as the radial artery of the upper extremity), there are often sufficient collateral circulation. After active non-surgical treatment, sufficient blood supply can be maintained, and no surgery is needed. Regardless of whether the collateral circulation of the diseased limb is sufficient, surgical removal should be considered to prevent the thrombus from extending to the distal and proximal ends, causing irreversible ischemic changes in the affected limb. Especially in the lower limbs, non-surgical treatment is not easy to be effective, and even if the diseased limb does not have gangrene, it will cause long-term chronic ischemic changes and cause disability. The sooner the operation should be performed, the better, preferably within 6-8 hours of onset; but it is not limited by this time. In some cases, the operation can still be successful after several days of onset. Treatment of diseases: abnormal muscle tone Indication Thromboembolism in the main arteries of the extremities, except for some parts (such as the radial artery of the upper extremity), there are often sufficient collateral circulation. After active non-surgical treatment, sufficient blood supply can be maintained, and no surgery is needed. Regardless of whether the collateral circulation of the diseased limb is sufficient, surgical removal should be considered to prevent the thrombus from extending to the distal and proximal ends, causing irreversible ischemic changes in the affected limb. Especially in the lower limbs, non-surgical treatment is not easy to be effective, and even if the diseased limb does not have gangrene, it will cause long-term chronic ischemic changes and cause disability. The sooner the operation should be performed, the better, preferably within 6-8 hours of onset; but it is not limited by this time. In some cases, the operation can still be successful after several days of onset. Surgery has a chance of success when the diseased limb has not been significantly gangrene and the blood in the distal blood vessel has not yet condensed. Although the burden of thrombectomy in the abdominal aortic bifurcation is heavy on the patient, if it is not given active treatment, it will lead to death, so surgery is more necessary. Except for patients who are already in a state of sudden death, they should try their best to obtain an opportunity for surgery and not give up easily. A thrombus at the bifurcation of the abdominal aorta can be removed through the abdomen or thigh. Either way, it is not always possible to achieve satisfactory results alone, but it is often necessary to use them together. Therefore, two ways should be prepared at the same time. Generally, the transabdominal route is used first; but for some patients with severe heart disease, the femoral artery can be removed first to remove the thrombus. If the thrombus obstruction cannot be relieved, add a transabdominal approach. Contraindications Older, combined with severe heart, liver, kidney and other diseases and difficult to tolerate surgery. Preoperative preparation 1. Positioning: Determine the location of thrombus obstruction from the color, temperature, sensation, pulse, etc. of the diseased limb (or angiography if necessary). 2. Skin preparation: Both the abdomen and the bilateral lower limbs should be prepared. 3. Determination of bleeding, coagulation, and prothrombin time: for anticoagulant therapy that may be needed during and after surgery. 4. Anticoagulant can be used before the operation of anticoagulant, usually intravenous injection of heparin 50 ~ 100mg, once every 6 hours, keep the clotting time in about 15 minutes. In the use of anticoagulant, the transfemoral approach can be performed as usual. Because the femoral artery is easy to expose, hemostasis is simple, and there is no need to worry too much about postoperative bleeding. However, try to avoid the transabdominal approach. If it must be used, Surgery was started 4 hours after the last heparin injection, or after an equal amount of protamine was used to neutralize heparin. 5. Sympathetic ganglion block: generally block the 2nd and 3rd lumbar sympathetic ganglia on both sides, each injection 1% procaine 10ml to relieve the reflex sputum of the diseased blood vessels, relieve ischemia and reduce pain. In order to gain time and early thrombectomy, it is not emphasized before use; but for delayed or postoperative cases, sympathetic ganglion blockade is very useful. During the use of anticoagulant, sympathetic ganglion block should be used with caution to avoid deep tissue hematoma. 6. Application of antispasmodic drugs: antispasmodic drugs (for example, intra-arterial injection of poppy sputum 0.03g above the thrombus obstruction site, or 1% procaine 5-10ml, 3 to 4 times a day), for relieving vasospasm It also works, but it is not very reliable. 7. Treatment of the limbs: Keep the limbs at a normal room temperature, put them slightly below the level of the heart, and wrap them with a large number of cotton pads to avoid trauma and compression, and keep warm. Freezing will cause vasoconstriction, heating will increase local metabolism, but promote tissue necrosis, should be disabled. 8. Cardiac treatment: The use of digitalis or diuretics in large quantities can promote the expansion of blood clots. The thrombectomy itself, especially under local anesthesia through the femoral route, can reduce the burden on the heart. Therefore, patients with severe heart disease should strive for early thrombectomy while properly treating heart disease. Surgical procedure 1. Position: supine position. The entire abdomen, groin and bilateral thighs to the knee joint should be disinfected. 2. Incision, exposure: midline incision in the abdomen or incision in the median side of the left side. After the abdomen, the gauze pad is used to push the transverse colon upward, and the small intestine is pushed to the right to reveal the lower part of the abdominal aorta and its bifurcation. The peritoneum was cut along the aorta and bilateral radial arteries. The location and extent of embolization were determined by observation and percussion. At the proximal end of the thrombus obstruction, the arterial pulsation is markedly powerful; but from the obstruction, the pulsation suddenly disappears. The artery at the blockage is enlarged, hard, and the wall of the tube is purple-red. Arteries that block the distal end tend to become thinner due to imperfections. When exploring, the technique should be gentle and gentle to prevent the thrombus fragments from falling off the distal artery. 3. Control the arteries: first separate the distal segment of the bilateral common iliac artery, each wrapped around a gauze band or a soft rubber tube, respectively, inject 20mg heparin solution, and then tighten the gauze band or add a non-destructive blood vessel clamp to prevent thrombus Spread on the far side. Then loop the upper abdominal aorta above the thrombus obstruction, wrap a gauze band or a soft rubber tube, and secure the aortic forceps, but do not close. If there is no suitable aortic forceps, the gauze can be tightened around the double ring to stop bleeding. 4. Open the abdominal aorta and remove the thrombus: the anterior wall of the abdominal aorta is cut about 2 cm long at the upper part of the bifurcation. The main thrombus protrudes from the incision. Then use your finger to squeeze the common artery on one side and then squeeze it on the other side, and squeeze the thrombus below the fork out of the incision. If the thrombus is not completely squeezed out, it can be squeezed from top to bottom with your fingers at the same time. The tougher thrombus can be driven out by the whole block. After the thrombus is expelled, the gauze band is tightened (or the aortic clamp is closed). The blood vessel clamps of the left and right common iliac arteries were alternately opened, and the remaining broken blood clots were washed out by retrograde blood flow, and the distal arteries were examined for patency. If the blood rushes out retrogradely, it indicates that the thrombus has been safely removed. However, if the countercurrent is slow, the internal iliac artery should be blocked first, and then the plastic tube of the appropriate thickness should be inserted into the distal end of the external iliac artery from the aortic incision to suck out the remaining thrombus. If it is still not smooth, an incision is required at the lateral femoral artery. First, use a finger to squeeze the blood clot from the bottom up and down the femoral artery, and use a syringe needle to puncture the femoral artery and wash it back with normal saline or light heparin solution; if necessary, cut the femoral artery and attract it with a suction tube (see the next section) Femoral route thrombectomy). 5. Suture the artery: suture the abdominal aortic incision with a thin wire or nylon thread for continuous or intermittent valgus valgus. Before suturing the last 2 to 3 needles, the blood vessel clamp of the bilateral common iliac artery is released, and the artery is filled with blood and exhausted. Then continue to sew and ligation, and then slowly loosen the tourniquet or aortic forceps of the abdominal aorta. If there is bleeding in the incision, generally use a dry gauze for a few minutes to stop bleeding, or use gelatin sponge to stop bleeding, if necessary, add 1 to 2 stitches. 6. Check the distal blood supply of the artery: After relaxing the aortic forceps, examine the pulsations of the bilateral radial, femoral, and radial arteries. If the femoral artery is unclear, the femoral artery must be examined before the abdominal cavity is closed, and it is incision and then attracted by a suction tube. The pulsation recovery of the radial artery or the dorsal artery of the foot is slower, especially in patients with longer heart disease and embolization, and can be added as a lumbar sympathetic ganglion block after surgery. 7. Suture the abdominal wall incision: After complete hemostasis, suture the peritoneal incision and suture the abdominal wall layer by layer. complication Bleeding, blood clotting.