Mennecart Thibaut, Normand Arthur, Lermusiaux Patrick, Millon Antoine, Della Schiava Nellie, Tresson Philippe
École de Santé des Armées, Bron, France.
Department of Vascular and Endovascular Surgery, Hopital Louis Pradel, Bron, France; Université Claude Bernard Lyon 1 (Univ Lyon), Villeurbanne, France.
Ann Vasc Surg. 2020 Aug;67:388-394. doi: 10.1016/j.avsg.2020.03.016. Epub 2020 Mar 21.
A distal approach in endovascular procedures for revascularization of lowers limbs can be considered in case of no re-entry in subintimal recanalization. The aim of this study is to evaluate the feasibility of a medial approach to the infrageniculate popliteal artery (IPA) using existing computed tomography (CT) scan simulation and punctures performed on cadavers.
CT angiographies of lower extremities were used to simulate IPA puncture and puncture trajectory. Tissues damaged during the trajectory between the puncture site and the access-related injuries were analyzed. Anatomical punctures on cadaverous model were also performed. Corpses were placed in supine position, the hip in slight flexion (40°) and abduction (external rotation of 60°). A 16 G needle was used for the IPA puncture. Twelve CT angiography simulations were made. Of these 12 simulations, 9 revealed an isolated lesion of the popliteal vein and 2 isolated lesions of the tibial nerve. A lesion of the tibial nerve and the popliteal vein on the same simulation was once observed. Damage to the medial gastrocnemius muscle could not be avoided in each case. Ten punctures were performed on cadavers with technical success. There were 6 popliteal vein lesions, 3 tibial nerve lesions, and 1 case without lesion. In all cases, damage to the medial gastrocnemius muscle was seen.
This medial approach was feasible and is accompanied by trauma of elements of the popliteal pedicle. Preoperative CT angiography could anticipate best site of puncture and potential access-related injury.
在下肢血管腔内再血管化手术中，如果内膜下再通无法重新进入，可以考虑采用远端入路。本研究的目的是利用现有的计算机断层扫描（CT）扫描模拟和在尸体上进行的穿刺，评估经内侧入路至腘窝下动脉（IPA）的可行性。
利用下肢CT血管造影来模拟IPA穿刺和穿刺轨迹。分析穿刺部位与入路相关损伤之间轨迹上受损的组织。还在尸体模型上进行了解剖穿刺。尸体置于仰卧位，髋关节轻度屈曲（40°）和外展（外旋60°）。使用16G针进行IPA穿刺。进行了12次CT血管造影模拟。在这12次模拟中，9次显示腘静脉孤立性损伤，2次显示胫神经孤立性损伤。曾在一次模拟中观察到胫神经和腘静脉同时损伤。在每种情况下都无法避免内侧腓肠肌损伤。在尸体上进行了10次穿刺，技术成功。有6次腘静脉损伤，3次胫神经损伤，1例无损伤。在所有病例中均可见内侧腓肠肌损伤。
这种内侧入路是可行的，并且伴有腘蒂结构的创伤。术前CT血管造影可以预测最佳穿刺部位和潜在的入路相关损伤。
