Outcomes of Proximal Hybrid Arterial Reconstruction in Combination with Simultaneous Amputation in Dry Atherosclerotic Gangrene of Toes

Abstract

INTRODUCTION: When treating atherosclerotic gangrene of the lower limb (LL), the surgeon faces the questions about the reasonability of vascular reconstruction and the optimal timing of amputation after surgery on the LL arteries. The answer to these questions is given by assessing the state of the microvasculature of the operated limb. With sufficient development of the microvasculature and good collateral circulation, it is possible to perform a simultaneous amputation after proximal reconstruction. In this situation, a clear demarcation of the zone of necrosis and reversible ischemia is required, which can be realized by the method of ultraviolet luminescence spectroscopy.

AIM: To analyze the results of hybrid reconstructions on the LL arteries with multilevel diffuse atherosclerotic lesions and dry gangrene of toes (DGT).

MATERIALS AND METHODS: A prospective, controlled, non-randomized study included 29 patients suffering from critical ischemia of the lower limbs and having DGT, who were operated on in the amount of hybrid arterial reconstruction. The patients were divided into two groups: patients of group 1 (n = 14) underwent restoration of the main blood flow at the level of the iliofemoral arterial segment using a hybrid method, with simultaneous minor amputation of LL at various levels; patients of group 2 (control group, n = 15) underwent a simultaneous proximal and distal hybrid operation, providing main blood flow through at least one of the lower leg arteries, followed by a minor amputation of the lower leg at various levels over the next 4–5 days.

RESULTS: There were no statistically significant differences in the groups in the degree of decrease in luminescence intensity after vascular surgery. A histological examination of intraoperative preparations of DGT revealed necrosis of the cellular microenvironment at luminescence amplitude > (1.0 ± 0.05) × 10⁵ photons at 410 nm frequency. At luminescence amplitude not exceeding this level, signs of necrobiosis were noted. Luminescence level of ≥ 1.0 × 10⁵ photons was used as the amputation boundary. In the case of an uncomplicated vascular stage of the operation, a comparable decrease in the conventional amputation boundary was noted in the study groups. In the early postoperative period, in patients of group 1, the level of inflammation markers, average number of bed-days, and the number of thrombotic complications were lower than in the control group (p < 0.05). A strong correlation was recorded between the morphological signs of the acute phase of inflammation and the intensity of chemiluminescence (r = 0.7, p < 0.005).

CONCLUSION: In patients with DGT, at a luminescence amplitude on the lower leg and foot not exceeding 1.0 × 10⁵ photons at 410 nm frequency and 0.7 × 10⁵ photons at 450 nm frequency, an effective treatment method is restoration of the main blood flow in the iliofemoral segment using a hybrid method with simultaneous minor amputation at various levels of the foot. This luminescence level is the conventional boundary between necrotic changes and reversible ischemia (necrobiosis) of the soft tissues of the LL.

Keywords

critical ischemia of lower limbs / hybrid operations / atherosclerotic gangrene / amputation, photoluminescence spectroscopy

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