Hybrid interventions for acute thrombosis after reconstructive operations on lower-limb arteries

Kuznetsov M.R.^1,2, Yasnopolskaya N.V.², Vinokurov I.A.^2,3, Fedorov E.E.², Shvedov P.N.²

¹ Institute of Cluster Oncology named after L.L. Levshin, I.M. Sechenov First Moscow State Medical University of the RF Ministry of Public Health,
² Department of Cardiovascular Surgery № 1, City Clinical Hospital named after S.S. Yudin under the Moscow Healthcare Department,
³ Chair of Hospital Surgery, Institute of Clinical Medicine named after N.V. Sklifosovsky, I.M. Sechenov First Moscow State Medical University of the RF Ministry of Public Health, Moscow, Russia

Background. A steadily growing number of primary lower extremity arterial reconstructions is inevitably followed by the need to perform repeat interventions. Shunt reocclusion may become a cause of return of ischaemia to the initial level, may significantly increase the degree of limb-threatening chronic ischaemia, as well as lead to the development of an acute condition requiring urgent corrective measures to be taken. A reoperation currently continues to remain the standard of treatment. Despite advances in modern resuscitation, the postoperative mortality rate in such patients reaches 20%.

Objective. This study was aimed at assessing feasibility of hybrid technologies in acute thrombosis after reconstructive operations on lower-limb arteries.

Patients and methods. We retrospectively analysed the results of treatment of 66 consecutive patients urgently admitted to the City Clinical Hospital named after S.S. Yudin from 2015 to 2020 with acute lower limb ischaemia caused by acute occlusion of the zone of primary vascular reconstructions previously performed at other medical facilities. Depending on the method of surgical treatment, the patients were divided into two groups. The Study group included 20 patients subjected to open surgical interventions followed by angiographic control and using one or other type of X-ray-endovascular treatment. Endovascular interventions were performed for more than 70% stenoses in the major arteries and zone of the previously performed operation. The Comparison group comprised 46 patients treated without endovascular technologies. They were subjected to thrombectomy from the vascular construction with/without reconstructive-restorative operations.

Results. Seventeen (85%) of the 20 Study group patients were operated on in a stagewise manner, with the first stage consisting of an open intervention – thrombectomy and reconstruction followed by angiographic control and roentgenendovascular treatment. The remaining three (15%) patients underwent simultaneous interventions.

In the postoperative period, limb amputations were performed in ten (22%) Comparison group patients and in one (5%) Study group patient (p=0.049). There were three (7%) lethal outcomes in the Comparison group, with none in the Study group.

Conclusion. A combination of open and endovascular interventions in patients with shunt occlusion after vascular reconstructions makes it possible to reveal the cause of shunt occlusion, as well as to remove multilevel lesions, minimizing surgical wound and contributing to reducing the amputation rate.

KEY WORDS: acute ischaemia, shunt thrombosis, hybrid interventions, repeat reconstructive vascular operations.

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