Abdominal aortic bifurcation thrombectomy by transfemoral approach

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. Treatment of diseases: arterial embolization of acute arterial embolism 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 The patient is too old and should be filled with poor general condition. 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: Anticoagulant can be used before surgery. Usually, heparin is administered intravenously 50-100mg once every 6 hours, and the clotting time is kept at 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. Incision: A longitudinal incision is made at each of the left and right femoral arteries, starting from the inguinal ligament and extending downward by about 6 to 7 cm. 2. Control the arteries: Cut the soft tissue outside the bilateral arteries, separate the femoral artery, and wrap a gauze band around each of its distal, proximal, and deep femoral arteries. After slowly injecting 20 ml of physiological saline containing 10-20 mg of heparin into one femoral artery, the gauze band of the deep femoral artery and the distal femoral artery (or the clip on each clip) was tensioned to control the distal blood flow. 3. Incision of the femoral artery and removal of the thrombus: the femoral artery was longitudinally cut between the upper and lower gauze bands by about 1 cm. Select a plastic suction tube that is slightly smaller than the artery diameter, cut the tip into a slanted opening, connect it to the aspirator with a glass tube, and cut a hole at the suction tube near the glass tube. The suction tube was inserted into the femoral artery from the vascular incision and advanced upward to observe the bleeding from the inside of the glass tube. When the tip of the suction tube contacts the thrombus and the bleeding in the glass tube stops, the aspirator can be actuated, and the side hole of the suction tube is pressed with the thumb to continue the suction, and the suction tube is slowly pulled together with the thrombus sucked at the tip thereof. Out. It is often necessary to repeat the intubation to attract several times. After the thrombus is removed, the femoral artery above the incision is clamped. The same method of contralateral femoral artery to clear the thrombus. Thrombosis can sometimes be pushed to the side that has been removed, so it may be necessary to re-suck on the opposite side until a strong and pulsating blood flow is seen from both sides of the artery. Then, loosen the gauze band or arterial clip at the distal end to check for smooth flow of blood from the femoral artery and deep femoral artery. After rushing off the blood clot, re-tighten the gauze band. 4. Suture incision: Each of the arterial incisions was sutured continuously with a 4-0 filament. After the blood leak is not detected, the femoral fascia and subcutaneous tissue are meticulously sutured to avoid dead space, so as to prevent oozing blood in the anticoagulation treatment. complication stomach ache.