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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3751_Библиотеки_им_академика_М_И_Перельмана
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FIGURE19.2 Axialcutofacomputedtomographywithaleftretroperitonealhematoma.
3.Radial,Brachial,andDistalLowerExtremityAccessSiteHemorrhage
Compared with femoral arterial access, rates of major bleeding (OR = 0.53), all-cause mortality
(OR=0.71),andmajoradversecardiovascularevents(OR=0.84)arelowerwithradialarterialaccess
in patients undergoing percutaneous coronary intervention according to a 2016 meta-analysis of over
22,000patients.8Thisisduetotheradialartery’ssmallercaliberandsuperficialcourse,limitinginternal
bleeding and allowing easy compression of external bleeding. Localized hematomas may require
extended manual compression of the arteriotomy site, arm elevation, and application of ice. If
unrecognized,however,hematomaformationwithinthewristmayspreadbrisklyfromlocalinfiltrationof
thesofttissuetoinvolvementofasignificantportionoftheforearm.Rarely,signsofvascularcompromise
including pain, pallor, paresthesia, and paralysis may ensue, signifying compartment syndrome and
requiringsurgicalevacuationtopreventtissuenecrosisandrestorevascularintegrity.
B.ArteriovenousFistula
An arteriovenous fistula (AVF) is an abnormal communication between an artery and a vein. The
incidence of clinically detected postcatheterization femoral AVF ranges from 0.006% to 0.86% from
publisheddataincludingonelargeprospectivestudysurveyingover10,000patientsfor3years.
9-14
When
routineduplexscanningisusedpostprocedure,thereportedincidenceinonestudywas2.8%,withall
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patientsbeingasymptomatic.15Themainetiologyisproximatepunctureofanarteryandveinsuchaswith
simultaneous right and left heart catheterization or through-and-through puncture of an artery into its
accompanying vein. Risk factors include low femoral puncture (below the bifurcation), left-sided or
multiple femoral punctures, simultaneous arterial andvenous access, higher levels of anticoagulation,
hypertension,andfemalegender.
16
The average shunt volumeof an iatrogenic fistula is 160-510 mL/min, less thanthat needed tocause
cardiacimpairment,whichtypicallyoccurswhenshuntvolumeisapproximately30%ofrestingcardiac
output.9Arterialinsufficiencyandvenoushypertensionarethetwomainconsequencesofarterial-venous
shunting.Flowwithinthedistalarteryisdiminishedorreversedwhentheareaofthefistulaexceedsthe
diameteroftheinflowarterybythreefoldandflowintheproximalarteryincreasesupto8-fold.
17,18
The
proximal veindiameter increases with increasingflow with no changein antegrade flow inthe distal
vein.19Overtime,theproximalarteryenlarges,andthinningofthearterialwallwithaneurysmaldilation
occurs.Theproximal vein,exposed topulsatile flow, also enlargesandthewall of the veinbecomes
arterialized.
20
1.Diagnosis
The history and physical examination may indicate the presence of an AVF. Most patients are
asymptomatic,andthemostcommonpresentingsignisthepresenceofapalpablethrillorbruitheardon
auscultation, or a pulsatile mass. Rarely, large fistulas with high shunt volumes may present with
symptomsrelatedtoarterialinsufficiency,venoushypertension,orhigh-outputcongestiveheartfailure.
Confirmation and characterization of an AVF can reliably be made with Doppler ultrasonography.
Findingsincludevisualizationofturbulentbidirectionalflowatthelevelofthefistula,lossoftriphasic
waveformsintheproximalarterywithhighpeaksystolicvelocities,decreasedflowinthedistalartery,
andelevatedpulsatilevenousoutflowpeaksystolicvelocities.
2.Management
The naturalhistory of iatrogenic AVFsis thatmany will close spontaneously. Onestudy witha 3-year
follow-up of postcatheterization femoral AVFs demonstrated a spontaneous closure rate of 38%, all
occurring within 1 year.Themedian timetoclosurewas3 months.9Asecond studyreported an 81%
spontaneousclosurerate,90% ofwhichwere closed within4 months.21Anticoagulationwas theonly
identifiedriskfactorforpersistenceofanAVF,whichinhibitsthrombusformationrequiredforclosure.
9
In lightofthis,asymptomaticsmall ormedium-sizedAVFsmay beconservativelymanaged with close
surveillancebyduplexultrasonography.
Forsymptomaticpatients,orthosewithlargeAVFsunlikelytospontaneouslycloseorlikelytoresultin
symptoms, intervention is indicated. The goal is closure of the fistula, normalization of cardiac and
circulatory hemodynamics, and reestablishment of vascular continuity. The use of duplex ultrasoundguidedcompressiontherapyhasbeengenerallyunsuccessful,renderingthisanunfavorablenoninvasive
treatmentoption.Endovascularandopensurgicalmanagementarethemainstaysoftherapy.Endovascular
techniques are generally reserved for high surgical risk patients or those with challenging anatomic
considerations such as marked obesity, prior groinsurgeries, or significant venous collaterals, which
increasebleedingrisk.
Endovascular options include embolization (using autologous clot, gelatin sponge, microfibrillar
collagen,polyvinylalcoholparticles,metalcoils,detachableballoons,andliquidagentssuchasN-butyl
cyanoacrylate)and,morecommonly,coveredstent-grafting.Theuseofintra-arterialcoveredstentsinthe
femoralpositionposestheriskofoccludingsidebranchesandlimitingfuturepercutaneousaccesssites.
SFAstentgraftsforiatrogenicfemoralAVFshaveareported1yearpatencyrateofgreaterthan80%.
22-25
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Surgicalrepairforacute orchronic AVFs is oftenthetreatmentofchoice forgoodsurgicalcandidates
withfavorableanatomy.InchronicAVFwithsignificantvenoushypertension,preoperativeendovascular
placementofarterialorvenousballoonsmayminimizebloodloss.Repairofthefistulausuallyrequires
proximalanddistalcontrolofbothvessels.Veinpatchangioplastyorinterpositionbypassgraftsareused
forrepairofalargeAVF.
C.Pseudoaneurysm
Pseudoaneurysms(PSAs),alsoknownasfalseaneurysms,resultfromacontainedruptureofthearterial
wall,andtheyformwhenthearteriotomysitehasnotsealedaftersheathremovalorwhenhemostasisis
disrupted.Arterialinjuryallowsforpulsatilebloodflowintotheconfinedadjacentperivascularspace,
whichcommunicateswiththearteriallumenthroughanarrowchannel,commonlyreferredtoasaneck.
Unliketrueaneurysms,PSAsdonotinvolveallthreelayersofthearterialwallandthereforeareproneto
rupture.Inthefemoralartery,PSAsareusuallycausedbylowarterialpuncture,asthespatialconstraints
ofthethighcontainthearterialrupture.MostPSAsoccurwithin3daysofsheathremoval.PSAsmaybe
complicated by distal embolization and extrinsic compression on adjacent neurovascular structures,
potentiallycausingneuropathy,deepvenousthrombosis,andrarely,localtissueorlimbischemia.
TheincidenceofPSAafterdiagnosticcatheterizationrangesfrom0.05%to2%andrisesashighas8%
when complexinterventions are performed, especiallywhen antithrombotic andantiplatelet therapy is
administered.
7,26-28
Onestudyreportedthat83%ofPSAswererelatedtointerventionalprocedures.
28
Several patientand procedural riskfactors contribute to theformation ofPSAs, themost important of
which are inadequate period of manual compression and low femoral arterial puncture (within the
superficialfemoralartery).Otherriskfactorsincludelargeboresheaths(>8F),useofanticoagulantand
antiplatelet therapy, obesity, hypertension, peripheral arterial disease, hemodialysis, complexity of
interventions,andadvancedage(>65yold).
29
1.Diagnosis
Patients with postcatheterization femoral artery PSA commonly present with pain and swelling inthe
affectedgroin.Signsorsymptomsofneuropathy,deepvenousthrombosis,localsofttissueischemia,or
acute limb ischemia due to distal thromboembolism may be present if the PSA is large enough to
compress neurovascular structures. Physical examination may demonstrate a pulsatile mass with a
systolic bruit. Some patients present with pain out of proportion to that which is expected from an
endovascular procedure, and in these cases, PSA should be definitively excluded. Some patients,
however,maybeentirelyasymptomaticandwithabenignphysicalexaminationinthesettingofasmall
PSA.
Thediagnosisisconfirmedbytheuseofduplexultrasonography,whichcarriesasensitivityof94%and
specificityof97%forthedetectionofPSA.30PSAsareidentifiedasanecholucentsaccommunicating
with the arterial lumen through a luminal channel (neck). Color Doppler may demonstrate pulsatile
swirlingflowintothesac(ying-yangsign),andpulsed-waveDopplerinterrogationofthenecktypically
demonstratesbloodflowintoandoutofthePSAsacandarteriallumen.ThesizeofthePSA,thepresence
andsizeofchambers,associatedneck,andvenousandarterialflowbothproximalanddistaltothePSA
shouldall be assessed carefullybyduplexultrasound. Incases whereduplex ultrasound (Fig.19.3) is
unavailable or the results are equivocal, intravenous contrast enhanced computed tomography (CT)
imagingcanbeusedtodiagnosePSA.
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FIGURE19.3 CommonfemoralarteryPSA.Noticethe“yin-yang”sign.
2.Management
StrategieswidelyavailableforthetreatmentofpostcatheterizationPSAincludeobservation,ultrasoundguided compression, ultrasound-guided thrombin injection, surgical repair, and in rare instances,
endovascularrepair.
In most cases of small (<2 cm) andasymptomatic PSA, spontaneous thrombosis and resolution often
occurs within 1 month.21 Surveillance duplex ultrasound is required to ensure resolution. Possible
activityrestriction,uncertaintyofclinicalcourse,andrepeatedultrasoundtestingaredownsidestothis
approach.
Ultrasound-guidedcompressionisanoninvasivetreatmentforuncomplicatedPSAswithasuccessrates
between 72% and 88%.
31,32
The technique is contraindicated in suprainguinal femoral artery and
anastomoticPSAs.TheultrasoundtransducerisusedtoapplydirectpressureovertheneckofthePSA,
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whichobstructsflowintotheaneurysmalsac,andthisisimmediatelyconfirmedwithDopplerimaging.
Compressionis appliedonaveragefor30-50minutesuntilthrombosiswithinthesacisachieved.This
techniqueis challenginginpatients whoareobese,onchronicanticoagulation,and/ordualanti-platelet
therapy, and those with large sized PSA (>4 cm). The presence of one or more of these factors
dramaticallyreducesthesuccessrateandraisescomplicationrates.
Ultrasound-guidedthrombininjectionisaminimallyinvasivemethodwidelyacceptedasthetreatmentof
choiceforuncomplicatedpostcatheterizationPSAwithanaveragesuccessrateofover95%asreported
by numerousstudies.29The technique involves the percutaneous injection of thrombin (as an off-label
use) into the PSA sac using ultrasound guidance. Compared with ultrasound-guided compression,
thrombininjectionisbettertolerated,carries a higherproceduralsuccessrate,andremainseffectivein
those on anticoagulation,with largePSAs, or when used in cases involving the suprainguinal femoral
artery.Arterialthrombosisisararebutknowncomplication,withthemajorityoccurringinsmallPSAs.
SurgicalrepairofpostcatheterizationPSAwasamainstayoftherapyuntilthe1990swhenpercutaneous
thrombininjectionwasintroduced.However,surgeryremainscriticalinthemanagementofPSAsthatare
rapid expanding, ruptured, infected, compressing adjacent neurovascular structures resulting in
neuropathy, limbor local tissue ischemia,orvenousthrombosis,orforthoselocatedatananastomotic
site.Surgicalrepairisoftenperformedforpostcatheterizationsuprainguinalfemoralandupperextremity
PSAsduetothehigherrateofassociatedneuropathyinbrachialarteryPSAs.Repairofthearterialwall
defect with interrupted polypropylene suture is most often performed, although patch angioplasty or
interpositionbypassgraftingmayberequiredinthecaseofsignificantinjury.
D.ArterialOcclusion
1.Femoral
Acutefemoral artery occlusion complicatesendovascular proceduresinless than0.8% of cases. Limb
ischemiaiscommonlyduetoembolismofwire-,catheter-,orsheath-associatedthrombus,oftenwhenthe
instrument is removed from the patient. The use of vascular closure devices with intra-arterial
components may resultin arterial occlusionby physical obstructionof a small caliber arterial lumen,
footplate-induced dislodgement of vascular plaque, or suture-mediated subintimal dissection and
subsequentthrombosis.
Risk factors include the presence and extent of vascular disease, small caliber arteries (women,
diabetics), low puncture site (superficial femoral or profunda femoris artery), larger sheath size and
indwellingtime,prolongedmanualcompression,low-flowstate,andhypercoagulabledisorder.
a.Diagnosis
Abrupt onset of any of the “6 P’s” should raise suspicion for acute limb ischemia: pain, pallor,
pulselessness,paresthesia,poikilothermia,andparalysis.Thromboembolicevents,includingcholesterol
embolifrom theuse ofwiresandcatheters indiseased vessels, mayresultindistal arterial occlusion
resultinginbluetoesyndrome,indicativeofdigitalischemia.Thediagnosisofarterialthrombosiscanbe
confirmedwithDopplerultrasonographyinuncertainandlow-riskcases.Otherwise,promptangiography
is often required toprecisely localize the lesion and forswiftintervention. Acute limb ischemia is a
medical emergencyand carries significantmorbidityand mortality if not expeditiously diagnosed and
accordinglytreated.
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b.Management
Immediatemanagementincludesinitiationofsystemicanticoagulation,usuallyintravenousunfractionated
heparin,andcontralateralaccess witheitherendovascularthrombectomy,catheterdirectedfibrinolysis,
orangioplastyandstenting.Ifpercutaneoustechniquesfail,swiftsurgicalthrombectomyorbypassmaybe
necessarytorestorebloodflowandavoidamputation.
Cannulation of the radial artery commonly results in arterial occlusion, with a reported incidence of
approximately10%.33Fortunately,thedualbloodsupplytothehandviatheulnararteryandpalmararch
renders nearlyall patients asymptomatic, although there are rare instances of ischemic complications.
Published data suggest that approximately half of all radial artery occlusions may spontaneously
recanalizewithin1month.
34
Nonmodifiableriskfactorsincludefemalegender,youngage,andperipheralvasculardisease.Theuseof
smaller profile sheaths, intra-operative anticoagulation, and avoidance of occlusive hemostasis can
mitigatetheriskofradialocclusion.Repeatedaccessattemptsraisetheriskofthrombosisslightly.One
studyof455patientsundergoingtransradialaccessshowedareductionintherateofradialocclusionby
color Doppler ultrasound before discharge from 30.5%to13.7% inthosepatients whoreceived a 5F
comparedwith6Fsheath.35Noneofthepatients developedcritical limbischemia. Onsheathremoval,
applicationoftheminimalamountofpressurerequiredtoachievehemostasisbutmaintainingantegrade
bloodflow,orpatenthemostasis,significantlyreducestherateofradialocclusionbasedontwoclinical
trials.Itisimportanttopreventradialocclusiontopreservetheaccesssiteforfutureprocedures,andfor
itsutilityindialysisfistulasandcoronarybypassgrafting.
Topreventischemiccomplications,someoperatorsmayperformthemodifiedAllentestorBarbeautest
to assess the patency of the ulnar and palmar vessels. The Allen test is performed by maintaining
occlusivemanualpressureontheradialandulnararterieswhileaskingthepatienttoclenchhisorherfist
severaltimesuntilthepalmisblanched.Releasingpressurefromtheulnararteryshouldreturnmaximal
blushtothepalmwithin9seconds.TheBarbeautestisamoreobjectivetestorulnopalmararchpatency
andisreportedtobemoresensitivethantheAllentest.Itisperformedbyfirstplacingapulseoximeter
onthethumborindexfingerofthehandtobetestedandensuringanormalbaselineoximeteryreading.
Then, occlusive pressure is applied to the radial artery, and the oximetry waveform is continually
assessed for 2 minutes. The response can be classified into 4 types: Type A, no change in oximetry
waveform;TypeB,dampingandeventualrecoveryoftheoximetrywaveformby2minutes;TypeC,loss
ofawaveformwithrecovery(evenifdamped)by2minutes;andTypeD,permanentlossofawaveform.
PatientswithaTypeCresponsehaverecruitmentofcollateralflowandwouldlikelyhavebeenexcluded
fromradialaccessbasedonanAllentestalone.PatientswithaTypeDresponse(1.5%ofpatients)have
nocollateralpulsatileflowandshouldnotundergoradialarterycatheterization.
Thediagnosisofradialarteryocclusionisreadilymadewhenapreviouslydetectedradialarterypulseis
nolongerpalpable.Onlyrarelydopatientsdevelopsymptomaticischemiawithpain,pallor,paresthesia,
poikilothermia,orparalysis.Uncertaincasescanbeconfirmedwithduplexultrasonography.
Treatmentisnotnecessaryforasymptomaticpatients.Patientswithsignsofcriticallimbischemiashould
undergourgentattemptatpercutaneousrevascularizationviaanantegradebrachialarteryapproachusing
thrombectomyand coronary balloons as needed.Surgical revascularization may be necessary in cases
whereanendovascularapproachisnotfeasibleorunsuccessful.
2.BrachialArtery
Theoverallrateofmajorbrachialcomplications(2.3%)hasbeenreportedtobeequivalenttothatseen
withfemoralaccess(2.0%)buthigherthanwithradialaccess(0%),inonerandomizedcontrolledtrialof
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900patients.36However,becauseofitsanatomicpositionasaterminalarteryandsmallerlumensize,it
israrelythepreferredsiteofaccess.
Thrombosis of the brachial artery will almost always lead to the devastating complication of limb
threateningischemia.Ratesofbrachialarteryocclusionintheliteraturearereportedtobeashighas6%;
however,withthe recent useoflowerprofilesheaths,theynowaverage 1%andaremore common in
thosewithsmallvesselssuchaswomen orthosewithextensivevasculardisease.37Asinallcases of
acute limb ischemia, prompt revascularization is necessary to prevent limb loss, and in the brachial
position,surgicaltherapyisusuallyrequired.
III.Intervention-SpecificComplications
E.Infection
Accesssiteinfectionfollowingclosurewithmanualcompressionisararecomplicationofendovascular
procedures.Thosethatdooccurmostofteninvolvethefemoralsiteatarateof<0.1%.26Althoughrare,
theyare potentiallyseriousgiventhe pathogen’s immediate access to the bloodstream andsubsequent
widespread dissemination. Risk factors include prolonged use of indwelling sheath, early reaccess,
presence of hematoma or PSA, diabetes, obesity, overlyingskin or soft tissue infection,andimmunecompromisedstate.Theuseofavascularaccessclosuredeviceraisestheincidenceofinfectionashigh
as5%.Retainedintravascularforeignmaterialmayserveas anidusforinfection,whichcarriesahigh
rateofmorbidityandmortality.MycoticPSAisthemostcommoncomplication.
1.Diagnosis
Patientsmaypresentwithfever,pain,tenderness,erythema,swelling,ordischargeattheinfectedaccess
site.Laboratorydataoftenrevealleukocytosis.Bloodculturesandduplexultrasonographymayassistin
makingthediagnosis.Accesssiteinfectionsinthesettingofclosuredeviceusepresentafteranaverage
of7-10dayswiththemostcommonlyisolatedorganismbeingStaphylococcusAureus(75%).
38
2."OUTLINE-END="outline-numbering-end-hereManagement
Prompt administration of intravenous antibiotics is the mainstay of treatment. In the case of severe
infection,commonlyinthesettingofanaccessclosuredevice,surgicaldebridementwithremovalofany
indwelling foreign material maybe necessary. In one retrospective review ofpatients with an access
closure device infection, all patients underwent surgical debridement, half of whom required
reconstructivesurgerywitha6%mortalityrate.
38
Insummaryvascularaccesscomplicationarerarebutcouldleadtosignificantmorbidityandmortality.
Henceoperatorsshouldbefamiliarwithriskfactors,clinicalsymptomsandsigns,andtreatmentoptions
forcomplicationsofvascularaccess.
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closuredevices.MayoClinProc.2005;80(8):1011-1015.
https://t.me/med1917
C H A P T E R 2 0
LimbSalvageFromaPodiatricStandpoint
MichaelI.GazesDPM,MPH,FACFAOM,AACFAS
PeterA.BlumeDPM,FACFAS
I.Introduction
II.InfectionControl
A.RiskFactors
B.Antibiotics
C.Examinations
D.Osteomyelitis
III.AdvancedWoundHealing
A.Phases
B.ExtracellularMatrix
C.NoninvasiveVascularStudies
IV.Summary
I.Introduction
Salvagingthe lowerextremity for functional, efficient, and low energyambulation is the ultimategoal
after ischemia, trauma, or infection in the lower extremity. Surgical emergencies exist, including gas
gangrene,septicjoints,anecrotizingfasciitis,whichcanleadtodramatictissueloss,complicatinglimb
salvageefforts(Fig.20.1).Peripheralneuropathy,leadingtoulcerations,deepsofttissuefootinfections,
andosteomyelitisalsorequirespecialanddedicatedcaretoavoidlossoflimband/orlife.
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