X-RAY ENDOVASCULAR SURGERY [rentgeno-(on a name B. X-ray) + Greek endon inside + lat. vasculum small vessel; surgery] — set of the intravascular chreskateterny diagnostic and medical manipulations which are carried out under X-ray inspection.
The term «X-ray endovascular surgery» was offered in 1979 by B. V. Petrovsky and And. X. Rabkin on the V All-Union symposium on X-ray contrast and endocardiac methods of a research. To R.'s development x. improvement of the diagnostic methods connected with catheterization of vessels, first of all promoted arteriography (see). River x. represents transition from diagnostic intravascular intervention to medical. Methods of X-ray endovascular surgery give the chance selective to lay down. impacts on the struck body in the conditions of the minimum injury.
Methods P. x. are divided into three basic groups: endovascular embolization, endovascular dilatation and long regional infusion.
Endovascular embolization it is based on introduction to a vessel through a catheter of any material (embolus), temporarily or constantly occlusive a gleam of a vessel. This method is used for a stop of bleeding, an artificial ishemization of tumors, for functional switching off of body, and also for elimination of aneurisms and arteriovenous fistulas. As emboluses apply various materials: autogenous tissues (blood clot, muscles, fatty tissue), glass, plastic, metals. Emboluses from autogenous tissues immunological are inert, sterile, and it is easy to receive them. The good embolizing stuff is the turned blood. Thanks to the elasticity the blood clot well fills a gleam of a vessel. For acceleration of formation of a clot add thrombin or thrombocytes to the blood received from the patient. The blood clot is suitable only for temporary occlusion of a vessel (from several hours to several days) since it quickly is exposed to a lysis. Apply emboluses from the oxidized cellulose to longer occlusion (oxyaiming) also from a gelatinous sponge (gelfam), used in surgery as gemostatik.
As the constant emboluses which are not exposed to lysis and fragmentation use balls from stainless steel, lead, siliko-nizirovanny rubber. All these materials shall be chemically inert, nepirogenna, are non-toxical and it is desirable rentgenokontrastna, shall not have antigenic properties. It is more convenient to use spongy materials, to-rye pass through a catheter in the compressed state, and having got to a circulatory bed, inflate and well fill a gleam of a vessel. The ivalonovy sponge (polyvinyl alcohol) belongs to such materials, e.g. For constant embolization use also fabric glues: isobutyl glue (bukrilat) and prepolymer of polyurethane, to-rye quickly polimerizuyuteya in blood also create foamy weight, densely okklyuziruyushchy a vessel. Unfortunately, these materials are toxic, it is inconvenient to work with them, the blockage of a catheter, gluing of material to vascular walls and a vyryvaniye of an embolus is possible during removal of a catheter from a vessel. Gianturko (S. of Gianturco) in 1975 suggested to use as an embolus a thin steel spring with the bunch of the strands of wood promoting a thrombogenesis attached on the end. The spring passes through a catheter in the straightened look, and getting to a vessel, is twisted in a spiral, fills its gleam. F. A. Serbinenko in 1973 offered and approved in clinic a catheter with the removable inflated microbarrel, to-ry becomes the constant not lysing embolus in a zone of aneurisms and patol. soustiya of vessels of a brain (see. Aneurism of vessels of a brain ).
The most frequent indication to endovaskulyarnon embolizations are bleedings (see). Embolization at acute, life-threatening bleedings has special value, at to-rykh conservative treatment unsuccessfully, and an operative measure is accompanied by big risk because of serious condition of the patient. The stop of bleeding with the help endovaskulyarnon embolizations allows to bring in such cases patients out of shock, to stabilize a state, to improve activity of cardiovascular system and then if it is necessary, to make an operative measure.
Endovascular embolization can be applied at gastrointestinal bleedings (see). The bleeding point is defined with the help rentgenol. researches or endoscopies also specify by means of the selection arteriography. At the same time the catheter is entered most close to an estimated bleeding point. By embolization it is possible to stop bleeding at a peptic ulcer of a stomach and duodenum, bleeding from a mucous membrane of a stomach, napr, connected with an extensive injury, surgery or sepsis, bleeding from varicose veins of a gullet. The method of endovascular embolization is applied and for a stop of bleeding from distal departments went. - kish. a path, diverticulums of intestines happen a source to-rykh often. At the same time it is necessary to consider that intestines have no such powerful collateral blood supply, a kaa a stomach and a duodenum. At damages of a liver and first of all at injuries, to-rye usually are followed by massive bleedings, especially at wounds of the right hepatic lobe, the selection arteriography (see. Tseliakografiya ) allows to define precisely a bleeding point, and endovascular embolization — quickly and reliably to stop it. Because embolization is made selectively, ischemia of certain sites of a liver is not followed by disturbance of its function. However it is necessary to be afraid of interruption of a blood-groove on a cholecystis artery (a. cystica) that can lead to a necrosis of a gall bladder. Endovascular embolization of bronchial arteries is of interest (bronchial branches of a chest part of an aorta, T.) at pulmonary bleedings (see. Pulmonary bleeding ), the vessels which developed because of anomalies, tuberculosis, hron. pneumonia, aspergillosis, tumor, etc. (fig. 1). After embolization of bronchial arteries at patients hron. pneumonia, except a stop of bleeding, expectoration also decreases.
There are data on successful treatment of nekorrigiruyemy nasal bleeding (see) by means of the selection catheterization and embolization of the bleeding small vessels.
Use of endovascular embolization for disturbance of blood supply of tumors is perspective. Preoperative obturation of the vessels feeding a tumor emboluses leads to the fact that vascularization of a tumor and its sizes decrease, and it znachrggelno facilitates an oncotomy and reduces danger of hit of tumor cells in a system blood stream during operation. Endovascular embolization can be applied and with the palliative purpose, at the same time the sizes of a tumor decrease, danger of bleeding is eliminated, pains stop. This method is used at tumors of kidneys, lungs, cases of its use at nonresectable tumors of a stomach, tumors of a liver, rectum are described.
Endovascular embolization can be made in need of functional switching off of this or that struck body. So, it finds application when the splenectomy at nek-ry diseases of system of blood (fig. 2) is shown. Endovascular embolization is applied to bilateral functional «nephrectomy» at patients in an end-stage renal failure (see) as stage of preparation for renal transplantation.
Endovascular embolization at various vascular anomalies is of interest — aneurisms, arteriovenous fistulas. So, successful results of embolization of pulmonary vessels at multiple arteriovenous fistulas in lungs are described. By means of this method it is possible to liquidate the arteriovenous fistulas which arose as a complication of a puncture biopsy of a kidney, aneurism of vessels of kidneys, the general or own hepatic artery. An opportunity to selectively catheterize and embolize such small vessels as arterioles, opens big perspectives of treatment of angiodysplasias (see. Blood vessels ).
Endovascular embolization is widely applied in neurosurgery, gynecology, and also in other fields of medicine. The procedure is painless, but after it pains, fever, vomiting, obviously, connected with a heart attack in a zone, krovosnabzhayemy an edobolizi-rovanny vessel can develop. Also fragmentation of an embolus, especially blood clot and gelatinous sponge, and its migration in distal departments of a vessel is possible. Danger of complications forces to support careful use of endovascular embolization, limiting its indications only to those cases so far, in to-rykh the risk of an operative measure is high and to recommend to apply this method in the centers with wide experience of the selection angiographic researches, the specialists who had special training on X-ray endovascular surgery.
Endovascular dilatation it began to be applied after emergence of works of Dotter (Ch. T. Dotter) et al. (1964) and W. Portsmann et al. (1973), offered a method of expansion of a gleam of a vessel at its atherosclerotic occlusion or a stenosis by means of special catheters. Now this method is widely used for treatment not only atherosclerotic, but also other damages of arteries of many bodies and systems of an organism. Endovascular dilatation of vessels is shown at occlusions or stenoses of the vessels no more than 100 mm long which are followed by heavy ischemia of bodies or fabrics in case of impossibility of carrying out reconstructive operation.
The essence of a method consists in a puncture of a vessel with the subsequent carrying out the metal conductor about-ksimalnee the stenosed site of a vessel. After that carry out a special catheter with an elastic cylinder to a vessel, to-ry under control of roentgenoscopy establish in a zone of a stenosis and fill with radiopaque substance that increases the volume of a cylinder. Then radiopaque substance is sucked away and the cylinder is fallen down. This manipulation is repeated several times. During all procedure and after it anticoagulants and antiagregant enter. Efficiency of dilatation is documented by a control angiography (fig. 3).
Favorable results of endovascular dilatation of a renal artery are received at renovascular hypertensia. Endovascular dilatation gives positive effect at stenoses of the renal arteries caused not only atherosclerosis, but also fibrous muskulyar - ache a dysplasia. In the latter case the stenosis is liquidated partially at the expense of stretching, and also at the expense of a rupture of fibers of fibrous fabric.
The positive takes received at dilatation of peripheral arteries allowed to carry out in 1977 Mr. of A. R. Gruntzig endovascular dilatation of coronary arteries at their stenosis. In the USSR endovascular dilatation of a coronary artery (fig. 4) was executed for the first time in 1982. And. X. Rabkin and A. M. Abugov. Endovascular dilatation of coronary vessels is shown to patients 60 years, lasting disease no more than 1 — 2 years, with the expressed retrosternal pains which are not stopped by means of pharmaceuticals with the proximal nekalyshchnirovanny stenosis no more than 10 mm long closing a gleam of one of coronary arteries more than for 70% are not more senior. These patients shall have a normal function of a left ventricle and sufficient passability of distal departments of coronary arteries.
Despite the seeming simplicity, use of a method demands big skill. The manipulation a catheter in the narrowed gleam of a coronary artery can cause interruption of a blood-groove, a separation of atheromatous masses or peeling of an internal cover, having caused development of a myocardial infarction. In this case the emergency operative measure aortocoronary shunting is necessary (see. Arterialization of a myocardium ). According to various researchers, the frequency of such complications reaches 10 — 13%. A contraindication to dilatation is the diffusion or multiple stenosis of several large branches of coronary arteries, stenoses more than 20 mm long, sharp bends and torsions of arteries, the site of a stenosis eccentric located, at Krom the catheter can penetrate an atherosclerotic plaque or a vascular wall. In the present vrvkhmya in the world more than 1200 endovascular dilatation of coronary arteries with a favorable result in of 85% are executed.
Long regional infusion. Efficiency of treatment of many serious illness depends on a possibility of creation in patol. center pile of high concentration of medicine. At usual methods of medicinal therapy it often happens is impracticable in connection with the systemic toxic effect of medicine, disturbance of blood circulation in patol. the center owing to occlusion of the feeding artery or other reasons. Use of a method of vnutriartsrpalny infusion by catheterization of a regional artery with continuous drop administration of drug gives the chance to create constant high concentration of medicine in the struck body. It is at the same time possible to carry out an angiography, edges gives an idea of a condition of blood circulation in the center of defeat.
The method of long regional infusion for the first time applied in clinic in 1959 by R. Sullivan as a method of regional chemotherapy of cancer, finds more and more broad application now, aspects of its use are proved and extend. Experience of use of a method of long regional infusion showed its high performance not only at oncological diseases, but also at various vascular pathology connected with disturbance of fibrinolitic activity of blood at bleedings, various inflammatory diseases and medical emergencies in surgery.
The method found the most wide spread occurance at acute and chronic thromboembolic defeats of vessels, especially at patients with high operational risk at fibrinferments after operations on vessels. Long regional infusion shall be applied in a complex with other methods of treatment, including and with operational.
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And. X. Rabkin.