Chayen David, Lorber Jonathan, Malic Zvi, Heldenberg Eitan, Itzhakov Zalman, Zaretsky Michael, Rabin Igor
Department of Vascular Surgery, Assaf Harofe Medical Center, Sackler Faculty of Medicine, Zerifin, Israel.
Department of Vascular Surgery, Assaf Harofe Medical Center, Sackler Faculty of Medicine, Zerifin, Israel.
Ann Vasc Surg. 2019 Nov;61:472.e15-472.e21. doi: 10.1016/j.avsg.2019.05.056. Epub 2019 Aug 8.
Arterialization of the foot veins in patients with ischemic foot usually result in excessive foot edema, wound infection, venous gangrene, long hospitalization duration, and a high rate of amputation. We herein present an improved method of foot revascularization via the superficial venous system by in situ reverse arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open.
A 69-year-old patient with toe wet gangrene and end-stage peripheral vascular disease with absence of foot target arteries underwent ISRA procedure, using the great saphenous vein, which was anastomosed end-to-side to the proximal superficial femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins.
Postoperatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Methoxyisobutylisonitrile scan conducted 4 weeks postoperatively demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the transmetatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks postoperatively. During 1,000 days of follow-up postsurgery, the flow was reduced and the transcutaneous pO level of the foot increased up to 76 mm Hg.
This new modified surgical technique of ISRA, in which only proximal saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of transcutaneous pO and reduced flow, leading to full recovery of the ischemic foot.
缺血性足病患者足部静脉动脉化通常会导致足部过度水肿、伤口感染、静脉坏疽、住院时间延长以及高截肢率。我们在此介绍一种通过足部静脉床原位逆向动脉化（ISRA）经浅静脉系统实现足部血运重建的改良方法，保留大隐静脉远端侧支开放。
一名69岁患有趾部湿性坏疽且终末期外周血管疾病、足部目标动脉缺失的患者接受了ISRA手术，使用大隐静脉，将其与股浅动脉近端进行端侧吻合。仅结扎近端大隐静脉属支，直至动脉血流到达足部浅静脉。
术后，足部浅静脉系统恢复正常搏动。患者未出现足部水肿。术中减影血管造影显示动脉血流经大隐静脉和足部背静脉，静脉血流经胫前和胫后静脉回流。术后4周进行的甲氧基异丁基异腈扫描显示足部肌肉有阳性氧摄取，术前无此现象。经跖骨截肢水平的肌肉电子显微镜检查显示术后6周肌肉组织有再生且有有丝分裂。术后1000天随访期间，血流减少，足部经皮氧分压水平升至76 mmHg。
这种新的改良ISRA手术技术，即仅结扎近端大隐静脉属支以防止足部静脉低压系统出现高体循环压力，导致经皮氧分压水平升高且血流减少，从而使缺血性足完全恢复。
