Results of Surgical Treatment of Patients with Critical Limb Ischemia

The study is dedicated to the analysis of the results of surgical treatment of patients suffering from chronic critical limb ischemia. The work examines the remote results of infrainguinal reconstructive vascular operations, including microsurgical arterial reconstructions, and evaluates patient survival and shunt patency. Special attention is paid to determining the quality of life of patients before surgery and in the remote period after the intervention using general and special questionnaires. Factors influencing the remote results of treatment and the change in quality of life have been identified, including the condition of the distal arterial bed and the degree of clinical improvement. The necessity of a comprehensive approach to evaluating the effectiveness of reconstruction, taking into account not only limb preservation and survival, but also the patient's social functioning, has been proven.

In the general structure of cardiovascular diseases, occlusive stenotic lesions of the arterial bed of the lower extremities occupy the second place, yielding precedence to ischemic heart disease. According to B.C. Saveliev (1997), chronic occlusive diseases of the lower extremities constitute 3-4% of the total number of surgical diseases. The experience of the Unified Vascular Research Group in the UK shows that in approximately 60% of cases, vascular reconstructions are performed for patients suffering from critical limb ischemia, in 20% - primary amputations, and in 20% - some other methods of temporary blood flow correction. Within a year, 25% of patients will undergo a major amputation, 55% - will preserve both legs, and 20% - will die. In the presence of damage only to the peripheral arteries, the mortality rate and the development of myocardial infarction are 84.9 and 21.2 per 1000 persons, respectively. Therefore, ischemia of the lower extremities threatens not only the loss of a limb but also poses a danger to the patient's life. (Wolfe JHN., 1986). Despite the achievements in the field of pharmacological treatment, surgical treatment remains one of the main methods for treating atherosclerotic lesions. Reconstructive surgical methods make it possible to preserve a limb in 45-55% of patients with critical limb ischemia for 5-8 years after the operation.

Direct revascularization eliminates the threat of amputation and symptoms of disabling intermittent claudication, improving the quality of life of patients. Angioplasty in the femoropopliteal segment in patients with critical ischemia, at local sites of stenosis/occlusion and preserved outflow pathways, allows limb preservation in 50-77% of cases over 2 years [99,162,164,183]. The effectiveness of operations depends on the state of the pathways, both inflow and outflow, as well as the used plastic material. A comparison of the patency of the "in situ" saphenous vein and the reversed saphenous vein in bypass grafting of the popliteal artery below the knee joint crease has been conducted in the Cochrane database [182]. It was found that there were no differences in primary patency (64% and 62%, respectively), secondary patency (65% and 70%), and limb preservation (74% in both groups) over a five- to ten-year period. According to various authors, the patency of femoropopliteal shunts over 5 years ranges from 41-70% [21,161,178]. The patency of femorotibial shunts over 5 years is 12.1-66% [21,70,83,220,228]. According to other authors, the 6-year patency of "in situ" saphenous vein shunts and reversed saphenous vein above the knee joint crease is 68.1% and 61.2%, respectively [21], and over 7 years the patency of grafts is 28% in both groups, with a sufficiently high percentage of preserved limbs - 70% using "in situ" and 50% using reversed saphenous vein [54]. The role of profundoplasty in the complex of operations on the femorodistal segment has long been recognized, but the question of whether isolated profundoplasty is capable of paralyzing the phenomena of limb ischemia remains controversial.

According to data from Chupin A.V. [86], arteriolization allowed limb preservation and improvement of its condition in the general group in 83.3% of patients, and in atherosclerosis in 93.3%. Over 5 years, the number of preserved limbs depending on the type of arteriolization was 79.4% and 93.3% when using the superficial and deep venous systems, respectively. Indirect revascularizing operations are an alternative to amputation.

Some authors note its high efficiency. Microvascular autotransplantation of the greater omentum was first proposed by N. Goldsmith and E.S. Alday in 1967 [72]. This intervention, in the opinion of I.I. Zatevakhin [38], is the operation of choice for patients with obliterating thromboangiitis with damage to the foot arteries with preservation of one or more patent artery in the calf or occlusion of all calf arteries with preservation of the popliteal artery and trifurcation [38]. The percentage of preserved limbs after femoropopliteal shunting over 5 years, according to various authors, ranges from 41% to 93% [196,220]. Patient survival according to various authors is 23%-78% [121, 220, 185]. The criterion of effectiveness of any reconstructive operation is the assessment of remote results.

Until recently, when assessing remote results after performing vascular reconstructive interventions, such indicators as limb preservation, cumulative patency of vascular shunts, and survival were taken into account. Currently, in clinical studies determining the success or failure of vascular reconstruction, the quality of life of the patient is the determining factor. Studies examining QoL show that the latter is significantly reduced in patients with occlusive diseases of the arteries of the lower extremities [23,40,58,107, 168, 208, 222], and also depends on the degree of ischemia [168,169].

According to Spanish scientists, the quality of life of patients with CLTI is significantly worse than in the healthy population, improves after treatment, but does not depend on the method of treatment [153].

The main goal of treatment is to return the patient to a state where they are able to achieve and maintain a level of social and public functioning, which is reflected in their life priorities and general well-being and therefore - in the quality of life.

The goal of the study: to improve the results of surgical treatment of patients with chronic critical limb ischemia. TASKS:

1. To study the remote results of microsurgical arterial reconstructions in chronic critical ischemia.

2. To clarify the life expectancy and causes of death of patients operated for critical limb ischemia and distal forms of damage.

3. To determine the quality of life of patients after reconstructive operations in patients with critical limb ischemia.

4. To identify the causes and factors affecting the change in quality of life in these patients.

Compare the quality of life of patients after vascular reconstructive operations and primary amputation. Scientific novelty:

The remote results of surgical treatment of patients with the clinical picture of chronic ischemia of the lower extremities have been studied using methods recommended in the document of the Russian Consensus of the Russian Society of Angiologists and Vascular Surgeons. The main factors affecting the remote results of infrainguinal reconstructive vascular operations have been identified. The quality of life of patients before surgery and in the remote period after surgery has been determined. The main factors affecting the quality of life of patients have been identified.

Practical significance:

The obtained data make it possible to consider the possibilities of improving the remote results of surgical treatment of patients with chronic ischemia of the lower extremities at distal lesions and to develop measures aimed at improving the quality of life. Thus, the main causes of mortality after infrainguinal reconstructions are lesions of other vascular basins, therefore, it is necessary to take an active tactic in the prevention and treatment of concomitant cardiovascular system diseases. The necessity of determining the quality of life in studies dedicated to studying the results of treatment of patients with chronic ischemia of the lower extremities has been proven, and it is advisable to simultaneously use general and special quality of life questionnaires.

Statistically significant differences in the results of operative treatment of patients in the remote period depending on the belonging to groups with good, satisfactory, or poor condition of the distal arterial bed, and the degree of clinical improvement after surgery have been determined.