Vasküler Yaralar: Arteryel İskemide Cerrahi ve Girişimsel Radyolojik Yöntemler
Özet
Bu çalışma, periferik arter hastalığının en şiddetli formu olan kritik bacak iskemisinde (KBİ) uygulanan cerrahi ve girişimsel radyolojik yöntemleri incelemektedir. Tedavide amaç; hızlı değerlendirme, kişiye özel strateji ve erken revaskülarizasyon ile uzuv kaybını önlemek ve yara bakımını sağlamaktır. Teşhiste renkli Doppler ultrasonografi ilk basamak iken, Bilgisayarlı Tomografi (BT) ve Manyetik Rezonans (MR) anjiyografi diğer önemli noninvaziv yöntemlerdir; anjiyografi ise altın standarttır. Lezyonların anatomik özelliklerine göre yapılan TASC II sınıflaması tedavi seçiminde yol göstericidir. Geleneksel açık cerrahi yöntemlerden endarterektomi, özellikle ana femoral arter bifurkasyonunda standart tedavi başarısını korumaktadır. Bypass cerrahisinde ise otolog safen ven greftleri, sentetik greftlere kıyasla daha yüksek uzun dönem açıklık oranları nedeniyle öncelikle tercih edilir. Minimal invaziv doğası ve gelişen teknoloji sayesinde endovasküler tedaviler (balon anjiyoplasti ve stentleme) günümüzde neredeyse tüm anatomik bölgelerde ilk seçenek haline gelmiştir. Aortoiliyak bölgede kissing balon/stent uygulamaları, femoropopliteal ve diz altı yerleşimli kompleks oklüzyonlarda ise subintimal geçiş veya retrograd pedal yaklaşımlar yüksek başarı sağlamaktadır. Son yıllarda, açık cerrahi ile endovasküler teknikleri birleştiren hibrid yaklaşımlar zorlu vakalarda efektif çözümler sunmaktadır. İşlem sonrası başarı, yakın Doppler takibi ve uzun süreli çift antiagregan tedavi ile desteklenmelidir.
This study examines the surgical and interventional radiological methods used in critical limb ischemia (CLI), the most severe presentation of peripheral artery disease. The primary goals of treatment are to prevent limb loss and ensure effective wound care through rapid evaluation, patient-specific strategies, and early revascularization. While color Doppler ultrasonography is the initial step in diagnosis, Computed Tomography (CT) and Magnetic Resonance (MR) angiography are other crucial noninvasive modalities, whereas conventional angiography remains the gold standard. The TASC II classification, based on the anatomical features of lesions, guides the choice of treatment. Among traditional open surgical methods, endarterectomy maintains its status as the standard treatment with high patency rates, particularly at the common femoral artery bifurcation. In bypass surgery, autologous saphenous vein grafts are primarily preferred over synthetic ones due to superior long-term durability. Due to their minimally invasive nature and evolving technology, endovascular treatments, including balloon angioplasty and stenting, have become the first-line option across almost all anatomical locations. Techniques such as kissing balloon/stent deployment in the aortoiliac segment, and subintimal passage or retrograde pedal approaches in complex femoropopliteal and below-the-knee occlusions, yield high success rates. Recently, hybrid approaches combining open surgery and endovascular techniques offer flexible solutions for challenging cases. Post-procedural success must be sustained through close Doppler follow-up and long-term dual antiplatelet therapy.
Referanslar
Elsayed S, Clavijo LC. Critical limb ischemia. Cardiol Clin. 2015 Feb;33(1):37-47.
Thukkani AK, Kinlay S. Endovascular intervention for peripheral artery disease. Circ Res. 2015;116:1599–1613.
Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45(Suppl S):S5e67.
Thukkani AK, Kinlay S. Endovascular intervention for peripheral artery disease. Circ Res. 2015;116:1599–1613.
Slovut DP, Lipsitz EC. Surgical technique and peripheral artery disease. Circulation. 2012;126:1127–1138..
Dos Santos JC. Leriche memorial lecture. From embolectomy to endarterectomy or the fall of a myth. J Cardiovasc Surg (Torino). 1976;17:113–128.
Malgor R, Ricotta J, Bower T, Oderich G, Kalra M, Duncan A, et al. Common femoral artery endarterectomy for lower-extremity ischemia: evaluating the need for additional distal limb revascularization. Ann Vasc Surg 2012;26:946-56.
Ballotta E, Gruppo M, Mazzalai F, Da Giau G. Common femoral artery endarterectomy for occlusive disease: an 8-year single-center prospective study. Surgery 2010;147:268-74.
Vartanian SM, Conte MS. Surgical intervention for peripheral arterial disease. Circ Res. 2015 Apr 24;116(9):1614-28.
Kang JL, Patel VI, Conrad MF, Lamuraglia GM, Chung TK, Cambria RP. Common femoral artery occlusive disease: contemporary results following surgical endarterectomy. J Vasc Surg. 2008;48:872–877.
Ballotta E, Gruppo M, Mazzalai F, Da Giau G. Common femoral artery endarterectomy for occlusive disease: an 8-year single-center prospective study. Surgery. 2010;147:268–274.
Nguyen BH, Amdur RL, Abugideiri M, et al. Postoperative complications after common femoral endarterectomy. J Vasc Surg. 2015; 61: 1489- 1494.
Falco E, Celoria G, Nardini A. Femoropopliteal bypass with reversed saphenous vein. Minerva Chir 1995; 50: 883-888.
Plecha EJ, Freischlag JA, Seabrook GR. Femoropopliteal bypass revisted an analysis of 138 cases. Cardiovasc Surg 1996; 4: 195-199.
Pereira CE, Albers M, Romiti M, Brochado-Neto FC, Pereira CA. Meta-analysis of femoropopliteal bypass grafts for lower extremity arterial insufficiency. J Vasc Surg. 2006;44:510–517.
Twine CP, McLain AD. Graft type for femoro-popliteal bypass surgery. Cochrane Database Syst Rev. 2010:CD001487.
Pomposelli FB, Kansal N, Hamdan AD, Belfield A, Sheahan M, Campbell DR, Skillman JJ, Logerfo FW. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg. 2003;37:307–315.
Soury PS, Pellion C, Watelet J, et al. Prosthetic reinforcement of varicose sapnenous vein grafts for infrainguinal bypass. Ann Vasc Surg 1999; 13: 290-393.
Prager M, Polterauer P, Böhmig HJ, Wagner O, Fügl A, Kretschmer G, Plohner M, Nanobashvili J, Huk I. Collagen versus gelatin-coated Dacron versus stretch polytetrafluoroethylene in abdominal aortic bifurcation graft surgery: results of a seven-year prospective, randomized multicenter trial. Surgery. 2001;130:408–414.
Faries PL, Logerfo FW, Arora S, Hook S, Pulling MC, Akbari CM, Campbell DR, Pomposelli FB Jr. A comparative study of alternative conduits for lower extremity revascularization: all-autogenous conduit versus prosthetic grafts. J Vasc Surg. 2000;32:1080–1090.
Dotter CT, Judkins MP. Transluminal Treatment of arteriosclerotic obstruction. Descripton of a new technic and preliminary report of its application. Circulation 1964; 30:654.
Gruntzig A, Hopff H. Percutane rekanalization chronischer arterieller verschlusse mit einem neuen dilatatationkatheter. Modifikation der Dotter-technik. Deutsch Med Worchenschr 1974; 99:2502.
Palmaz JC, Sibbitt RR, Reuter SR, et al. Expandable intraluminal graft: a preliminary study. Work in progress. Radiology 1985; 156:73.
Höfling B, Simpson JB, Remberger K, et al. Percutaneous atherectomy in iliac, femoral and popliteal arteries. Klin Wochenschr 1987; 65:528.
Werner GS, Buchwald A, von Romatowski J, et al. [Excimer laser angioplasty in arterial obstructive disease. Clinical experience with guidewire-controlled catheter systems]. Dtsch Med Wochenschr 1989; 114:1271.
Sousa JE, Costa MA, Abizaid A, et al. Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation 2001;103:192.
Scheller B, Hehrlein C, Bocksch W, Rutsch W, Haghi D, Dietz U, Böhm M, Speck U. Treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter. N Engl J Med. 2006 Nov 16;355(20):2113-24..
Egorova NN, Guillerme S, Gelijns A, et al. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg 2010; 51:878.
Ascher E, Hingorani A, Markevich N, et al. Lower extremity revascularization without preoperative contrast arteriography: experience with duplex ultrasound arterial mapping in 485 cases. Ann Vasc Surg 2002; 16:108.
8. Block PC, Baughman KL, Pasternak RC, Fallon JT. Transluminal angioplasty: correlation of morphologic and angiographic findings in an experimental model. Circulation 1980;61:778-85.
Bosiers M, Deloose K. Superficial femoral and popliteal artery disease. In Kumar A, Quriel K, editors. Handbook of endovascular interventions. Springer New York; 2013.p.349-63.
Klonaris C, Katsargyris A, Tsekouras N, Alexandrou A, Giannopoulos A, Bastounis E. Primary stenting for aortic lesions: from single stenoses to total aortoiliac occlusions. J Vasc Surg 2008; 47: 310-7.
Jongkind V, Akkersdijk GJ, Yeung KK, Wisselink W. A systematic review of endovascular treatment of extensive aortoiliac occlusive disease. J Vasc Surg 2010;52: 1376-83.
Muradin GS, Bosch JL, Stijnen T, Hunink MG. Balloon dilation and stent implantationfor treatment of femoropopliteal arterial disease: meta-analysis. Radiology 2001;221:137.
Rocha-Singh KJ, Jaff MR, Crabtree TR, et al. Performance goals and endpoint assessments for clinical trials of femoropopliteal bare nitinol stents in patients with symptomatic peripheral arterial disease. Catheter Cardiovasc Interv 2007; 69:910.
Matsumura JS, Yamanouchi D, Goldstein JA, et al. The United States StuDy for EvalUating EndovasculaR TreAtments of Lesions in the Superficial Femoral Artery and Proximal Popliteal By usIng the Protégé EverfLex NitInol STent SYstem II (DURABILITY II). J Vasc Surg 2013; 58:73.
Bosiers M, Deloose K, Callaert J, et al. Results of the Protégé EverFlex 200-mm-long nitinol stent (ev3) in TASC C and D femoropopliteal lesions. J Vasc Surg 2011; 54:1042.
Aljarrah Q, Allouh MZ, Bakkar S, et al. Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community. BMC Surg. 2019 Nov 13;19(1):170.
Armstrong EJ, Armstrong DG. Critical limb ischemia. Vasc Med. 2021 Apr;26(2):228-231. Epub 2021 Feb 15. PMID: 33587691.
Liistro F, Angioli P, Ventoruzzo G, et al. Randomized Controlled Trial of Acotec Drug- Eluting Balloon Versus Plain Balloon for Below-the-Knee Angioplasty. JACC Cardiovasc Interv 2020; 13:2277.
Ipema J, Huizing E, Schreve MA, et al. Editor's Choice - Drug Coated Balloon Angioplasty vs. Standard Percutaneous Transluminal Angioplasty in Below the Knee Peripheral Arterial Disease: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2020; 59:265.
Patel A, Irani FG, Pua U, et al. Randomized Controlled Trial Comparing Drug-coated Balloon Angioplasty versus Conventional Balloon Angioplasty for Treating Below-the- Knee Arteries in Critical Limb Ischemia: The SINGA-PACLI Trial. Radiology 2021;300:715.
