Автор: Аверина Олеся Валерьевна, к.м.н., врач-патолог, преподаватель кафедры паталогической анатомии и патологической физиологии
Шунтирование сосудов нижних конечностей – оперативное вмешательство, позволяющее восстановить нормальный кровоток в ногах. Заключается в создании обходного пути (шунта), исключающую зону поражения из кровотока. Обычно проводится на артериях нижних конечностей, но в некоторых случаях показаны вмешательства и на венах. Операцию проводят исключительно высококвалифицированные и опытные хирурги в специализированных клиниках после того, как пациенты будут полностью обследованы, и подтвердится необходимость подобной процедуры.
Применяемые шунты бывают двух видов: биологические и механические:
- Биологические или натуральные шунты изготавливают из аутоматериала — ткани собственного организма. Это достаточно прочные шунты, способные удержать артериальный кровоток на небольшом участке. Родная ткань организма применяется достаточно широко. Хирурги отдают предпочтение аутотрансплантатам из подкожной бедренной вены, внутренней грудной артерии, лучевой артерии предплечья. Если площадь поражения большая, а состояние сосудистой стенки неудовлетворительное, используют синтетические имплантаты.
- Механические или синтетические шунты получают из полимеров. Синтетические сосуды-протезы используют при шунтировании крупных сосудов, испытывающих давление мощного потока крови.
Существуют многоэтажные шунты, которые применяют при наличии артерий с нарушением проходимости на значительном расстоянии. Образующиеся при этом короткие анастомозы выполняют роль соединительных мостиков со здоровыми участками.
Поражение сосудов нижних конечностей наблюдается чаще, чем других периферических. Шунтирование назначают больным при отсутствии терапевтического эффекта от консервативного лечения. Структура и функции сосудов ног патологически изменяются при аневризме, артериите, варикозе, атеросклерозе, гангрене.
шунтирование сосудов нижних конечностей
Здоровые артериальные сосуды с гладкой поверхностью поражаются, их стенки становятся твердыми и хрупкими, кальцинируются, покрываются холестериновыми бляшками, закупориваются сформированными тромбами, суживающими просвет и вызывающими нарушение кровотока. Если препятствие току крови имеет большие размеры, появляются длительные боли в икроножных мышцах, снижается подвижность конечности. Больные быстро устают при ходьбе, часто останавливаются и ждут, когда боль пройдет. Прогрессирующая деформация сосудов и полное перекрытие их просвета приводят к нарушению кровоснабжения ткани, развитию ишемии и некроза. При отсутствии ожидаемого эффекта от медикаментозной терапии прибегают к операции.
нарушение кровоснабжения ткани и развитие гангрены
Поражение вен, в свою очередь, проявляется слабостью венозной стенки, извитостью вен, их расширением, формированием тромбов, развитием трофических нарушений. При риске развития тяжелых осложнений пациентам также может быть показано шунтирование.
Шунтирование сосудов в настоящее время проводится преимущественно тем пациентам, которым противопоказана эндоваскулярная хирургия. Шунт присоединяют с сосуду одним концом выше места поражения, а другим — ниже. Так создается обходной путь вокруг участка кровеносного сосуда, пораженного заболеванием. Благодаря оперативному вмешательству удается полностью восстановить кровоток, избежать развития гангрены и ампутации конечности.
Показания и противопоказания
Шунтирование нижних конечностей – непростая процедура, которая должна выполняться по строгим показаниям. Операция проводится врачами-ангиохирургами в следующих случаях:
- Аневризма периферических артерий,
- Атеросклеротическое поражение артерий,
- Облитерирующий эндартериит,
- Начинающаяся гангрена ног,
- Варикозное расширение вен,
- Тромбоз и тромбофлебит,
- Невозможность использования эндоваскулярных и альтернативных методик,
- Отсутствие эффекта от медикаментозного лечения.
Шунтирование сосудов обычно не проводится в случае:
- Возможности успешного проведения ангиопластики,
- Обездвиженности больного,
- Неудовлетворительного общего состояния больного,
- Заболевания внутренних органов в стадии декомпенсации.
Диагностика
Специалисты-ангиохирурги перед проведением шунтирования опрашивают больного, выясняют имеющиеся у него сопутствующие заболевания, осматривают и направляют на специальное диагностическое обследование, включающее:
- Клинические анализы крови и мочи на все основные показатели.
- Электрокардиографию.
- Магнитно-резонансную томографию, которая позволяет просмотреть структурные изменения сосудов и определить степень их проходимости.
- Компьютерную томографию, определяющую степень обтурации кровеносного сосуда холестериновой бляшкой.
- Дуплексное УЗИ, оценивающее состояние кровотока и сосудистой стенки.
- Ангиографию – рентгеноконтрастное исследование, позволяющее определить на рентгеновском снимке место сужения или закупорки сосуда.
После получения результатов УЗИ и томографии назначается подготовительный период к операции, во время которого больные обязаны соблюдать правильное питание и принимать специальные препараты: «Аспирин» или «Кардиомагнил» для профилактики тромбообразования, лекарства из группы антибактериальных средств и НПВП. За 7-12 часов до начала операции пациентам следует прекратить принимать пищу.
Оперативное вмешательство
Шунтирование сосудов ног – сложная операция, требующая от хирурга высокого профессионализма и определенного опыта работы. Операция выполняется под общей или местной анестезией, что обусловлено медицинскими показаниями и общим состоянием больных. Эпидуральная анестезия считается современным приоритетным методом обезболивания, существенно снижающим операционный риск.
Шунтирование проводят при нарушении проходимости артериальных и венозных стволов, если их обтурация составляет более 50% диаметра. В ходе операции создают обходной путь с помощью трансплантата от начала препятствия и до его конца. Правильно проведенная операция обеспечивает восстановление тока крови в пораженных сосудах.
Существует несколько вариантов шунтирования. Выбор каждого определяется локализацией области поражения. Сразу после операции больным надевают кислородную маску и вводят внутривенно капельно обезболивающие средства.
Первые двое суток после операции больным показан постельный режим. Затем пациентам разрешают ходить по палате и коридору. Снять боль и уменьшить отечность травмированных тканей в течение первых суток помогут холодные компрессы, поставленные на 20 минут. Всем пациентам рекомендуют носить компрессионные чулки и носки для предупреждения тромбообразования. Для улучшения работы легких следует применять стимулирующий спирометр. Ежедневно врачи осматривают разрезы на предмет возможного инфицирования. В течение 10 дней после операции специалисты ведут динамическое наблюдение за пациентом, исследуя показатели основных жизненных функций организма.
Шунтирование сосудов не устраняет этиологический фактор патологии, а лишь облегчает ее течение и состояние больных. Комплексное лечение основного заболевания включает не только проведение операции, но также изменение образа жизни, препятствующее дальнейшему развитию патологического процесса.
Послеоперационный период
Организм пациента после операции восстанавливается относительно быстро. На седьмой день хирурги снимают швы, оценивают общее состояние больного и выписывают его из стационара на 10-14 день.
Правила, которые необходимо выполнять в послеоперационном периоде:
- Соблюдать диету и не употреблять продукты, содержащие холестерин и способствующие набору веса.
- Принимать препараты, препятствующие тромбозу и снижающие уровень холестерина в крови.
- Работать с врачом-физиотерапевтом.
- Ходить, ежедневно увеличивая расстояние.
- Фиксировать в приподнятом положении конечности во время сна.
- Проводить гигиеническую обработку послеоперационных ран.
- Выполнять несложные физические упражнения, улучшающие циркуляции крови в ногах.
- Нормализовать массу тела.
- Периодически сдавать анализы крови с целью определения тромбоцитов и холестерина.
- Отказаться от курения и алкоголя.
- Лечить сопутствующие заболевания.
- Выполнять рекомендации врачей-ангиохирургов.
- При возникновении проблем в месте операции незамедлительно обратиться к врачу.
У больных количество и величина разрезов на ногах зависят от числа шунтов и протяженности очага поражения. После операции на голеностопных суставах часто возникают отеки. Пациенты ощущают неприятное жжение в местах изъятия вен. Это чувство становится особенно острым в положении стоя и по ночам.
После шунтирования сосудов восстановление функции конечности происходит в течение двух месяцев, а общее состояние больного улучшается практически сразу: уменьшается или исчезает боль в ноге, постепенно возобновляется ее двигательная активность. Чтобы ускорить данный процесс и вернуть силу мышцам, пациенту следует приложить усилия и разрабатывать их.
Продолжительность полноценной жизни после шунтирования сосудов варьируется и зависит от возраста пациента, половой принадлежности, наличия вредных привычек и сопутствующих заболеваний, соблюдения рекомендаций врача. Обычно больные, которым проводится операция, страдают тяжелой формой атеросклероза сосудов. Смерть у них в большинстве случаев наступает от ишемии миокарда или мозговой ткани (инфаркт, инсульт). Если шунтирование сосудов ног окажется безуспешной операций, больным грозит ампутация конечности и смерть на фоне гиподинамии.
Осложнения
Осложнения, которые могут возникнуть после шунтирования сосудов ног:
- Кровотечение,
- Тромбоз кровеносных сосудов,
- Вторичное инфицирование,
- Несостоятельность швов,
- Тромбоэмболия легочной артерии,
- Аллергия на наркоз,
- Острая коронарная и мозговая недостаточность,
- Сердечный приступ,
- Неполная проходимость шунта,
- Плохое заживление раны,
- Летальный исход.
Проведение антисептических и асептических мероприятий позволяет исключить развитие подобных проблем.
Существуют также осложнения, которые возникают не после операции, а во время нее. К наиболее распространенным интраоперационным осложнением относится выделение сосуда, непригодного для шунтирования. Чтобы предотвратить подобное явление, необходимо качественно и подробно проводить предоперационную диагностику.
Подобные осложнения чаще всего возникают у лиц, входящих в группу риска и имеющих следующие проблемы:
- Гипертония,
- Избыточная масса тела,
- Гиперхолестеринемия,
- Гиподинамия,
- ХОБЛ,
- Сахарный диабет,
- Заболевания почек,
- Сердечная недостаточность,
- Табакокурение.
После операции боль и онемение в ногах становятся менее выраженными. Симптомы болезни могут возобновиться спустя некоторое время, что обусловлено распространением патологического процесса на соседние артерии и вены. Шунтирование сосудов не лечит атеросклероз и варикоз и не устраняет причину поражения сосудов.
Профилактика
Шунты обычно могут нормально функционировать в течение 5 лет, если регулярно проходить медицинские обследования и проводить мероприятия по профилактике тромбоза.
Специалисты рекомендуют больным:
- Бороться с вредными привычками,
- Нормализовать массу тела,
- Следить за питанием, исключая высококалорийные и жирные продукты,
- Поддерживать физическую активность на оптимальном уровне,
- Принимать препараты, препятствующие развитию тромбоза «Аспирин Кардио», «Тромбо Асс», «Кардиомагнил»,
- Принимать средства от атеросклероза – «Ловастатин», «Аторвастатин», «Атромидин», «Клофибрин»,
- Регулярно посещать сосудистого хирурга.
Артериальное шунтирование в настоящее время проводят чаще, чем венозное, что обусловлено наибольшей распространенностью патологии артерий. Эта операция часто становится единственный способом борьбы с тяжелыми проявлениями артериальной недостаточности. Хирургическое вмешательство значительно улучшает качество жизни больных и предупреждает развитие гангрены нижних конечностей.
Видео: лекция об атеросклерозе НК, его лечении и операциях на артериях
Болезни периферических артерий вызваны образованием в них атеросклеротических бляшек. У многих людей заболевание никак не проявляется и не требует специального лечения, кроме устранения факторов риска, прежде всего курения. Когда препятствие кровотоку становится больше, появляются длительные боли, снижение подвижности. В тяжелых случаях необходима ампутация конечности. Для больных с выраженной ишемией рассматриваются хирургические методы улучшения кровотока – шунтирование сосудов нижних конечностей или малоинвазивные вмешательства (ангиопластика и стентирование). Они позволяют нормализовать приток крови к конечности, снять боли, восстановить подвижность, предотвратить ампутацию и улучшить качество жизни.
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Показания для шунтирования
Для пациентов, у которых невозможно выполнить ангиопластику, шунтирование сосудов на ногах – очень эффективная процедура. В ходе операции хирурги создают альтернативный путь кровотока в обход области закупорки артерии, что позволяет восстановить кровоснабжение голени и стопы.
Операция выполняется в случае неэффективности медикаментозного лечения при следующих заболеваниях:
- атеросклероз артерий нижних конечностей, вызванный холестериновой бляшкой;
- облитерирующий эндартериит – сужение просвета артерий вследствие воспаления их стенки.
Заболевания сосудов, являющиеся показанием для проведения шунтирования сосудов нижних конечностей
Шунтирование выполняется также в случае тяжелой аневризмы артерий с угрозой ее разрыва и нарушением питания тканей. Оно нередко позволяет сохранить конечность при сильных болях и угрозе гангрены.
Варианты проведения вмешательства
Варианты шунтирования называются в зависимости от соединяемых сосудов:
аорто-бифеморальное: кровь направляется из брюшной аорты в две бедренные артерии в области паха;- бедренно-подколенное: кровоток идет из бедренной артерии в подколенную выше или ниже колена;
- феморотибиальное или бедренно-берцовое: соединяются бедренная и берцовые артерии на голени.
Соединение артерий проводят с помощью шунта. Это может быть собственный сосуд пациента – подкожная вена бедра. Если ее состояние недостаточно хорошее, или она имеет малую длину, или в случае соединения крупных артерий применяются синтетические трансплантаты.
Оценка состояния перед операцией
Врач подробно расспрашивает пациента о жалобах, времени их появления, сопутствующих заболеваниях. Он проводит тщательный осмотр ног, определяет кожную температуру, окраску кожи, пульсацию периферических артерий, выявляет нарушения чувствительности и другие объективные признаки заболевания.
Дополнительно используются такие диагностические тесты:
- определение давления и пульсации в паховой, подколенной областях и над лодыжками для предварительного определения места закупорки;
- допплерография сосуда – ультразвуковое исследование скорости кровотока, позволяющее точно определить место поражения;
- ангиография – рентгенологический метод, позволяющий зафиксировать на рентгенограмме все артериальные сосуды конечности;
- спиральная компьютерная или магнитно-резонансная ангиография – современные, более безопасные и точные методы по сравнению со стандартной ангиографией.
Выполняется анализ крови с определением уровня холестерина, сахара крови и других показателей. Также врачи ищут признаки воспаления, которое может быть причиной сужения артерий.
Методика проведения
Шунтирование сосудов ног проводится под общей анестезией. При бедренно-подколенном или феморотибиальном способе хирург делает разрез кожи в верхней части бедра, чтобы обнажить артерию выше места закупорки. Кроме того, выполняется разрез под коленом или на голени ниже места артериального тромбоза. Артерию перекрывают с помощью зажимов.
При использовании собственной вены пациента хирург выделяет ее с передней поверхности бедра. Если сосуд не подходит для трансплантации, используется трубчатый синтетический протез. Хирург соединяет края артерий и трансплантата с помощью микрохирургической техники. Зажимы удаляют и наблюдают за потоком крови по новому руслу, чтобы убедиться, что обходной путь функционирует нормально.
При этих видах операции собственный сосуд пациента предпочтительнее, потому что он дольше сохраняет нормальный просвет и не тромбируется.
Аорто-бифеморальное шунтирование выполняется во многом так же, но требуются разрезы в нижней части живота и в паховой области. Нижняя брюшная аорта – крупный сосуд, поэтому подкожная вена не используется, а применяется синтетический трансплантат.
Сразу после операции назначаются антикоагулянты для профилактики свертывания крови в трансплантате.
Реабилитационный период
После шунтирования пациента в течение часа наблюдают в послеоперационной палате, где проводят мониторирование артериального давления, пульса, содержания кислорода в крови и других важных показателей. Регулярно оценивают состояние кровотока.
В дальнейшем пациент переводится в хирургическое отделение, где его регулярно осматривают и перевязывают. Время пребывания в стационаре при бедренно-подколенном и феморотибиальном шунтировании обычно составляет несколько дней. Такие пациенты могут начинать ходить уже в день операции.
При аорто-бифеморальном шунтировании пациент находится в больнице около недели. В течение первых 2 суток он должен соблюдать постельный режим.
Рекомендации по восстановлению
После операции необходимо воздержание от курения. По назначению врача следует принимать аспирин и препараты для снижения уровня холестерина. Обязательно нужно лечить сопутствующие заболевания – диабет, атеросклероз, гипертонию, иначе шунт скоро снова затромбируется.
Снижение просвета артерий нередко распространяется на большое расстояние, поэтому часто необходимы длинные разрезы. Проблемы, связанные с заживлением раны, возникают у 20% пациентов.
Если они выражены незначительно, в домашних условиях необходимо применять антибиотики и регулярно выполнять перевязки. При серьезных осложнениях требуется повторная госпитализация.
Чтобы свести эти проблемы к минимуму, необходимо тщательное соблюдение техники операции и качественный послеоперационный уход. В этом случае срок службы аутовенозного трансплантата у большинства больных составляет 5 и более лет. Для оценки состояния кровотока необходимо регулярное наблюдение у врача и выполнение допплерографии сосудов.
Также больным рекомендуют в первое время соблюдать диету для скорейшего восстановления.
Противопоказания
Шунтирование сосудов – серьезное оперативное вмешательство. Оно может быть противопоказано пациентам с высоким риском сердечно-сосудистых осложнений:
- высокое артериальное давление, плохо поддающееся лечению;
- тяжелая сердечная недостаточность с одышкой и отеками в покое;
- частые приступы стенокардии;
- аневризма сердца;
- тяжелые нарушения сердечного ритма – фибрилляция предсердий, желудочковая тахикардия и другие.
Осложнения
Как любое хирургическое вмешательство, операция шунтирования может иметь различные осложнения, их частота достигает 2%:
- образование тромба в венозном трансплантате;
- аллергическая реакция на обезболивающий препарат;
- эмболия сосудов сердца, легких или мозга с развитием инфаркта или инсульта;
- повышение или резкое снижение артериального давления;
- инфицирование раны;
- кровотечение из раны;
- сексуальные нарушения при аорто-бифеморальном шунтировании.
Больные с атеросклерозом сосудов ног часто страдают сопутствующими заболеваниями сердца, поэтому перед операцией необходимо тщательное обследование и оценка риска вмешательства. До и после процедуры необходим прием аспирина и препаратов, снижающих уровень холестерина и артериальное давление.
Другая группа осложнений связана с конечностью и включает недостаточную проходимость анастомоза и плохое заживление раны.
В целом операция проходит успешно в 90 — 95% случаев. Риск и отдаленные последствия вмешательства связаны с двумя главными факторами:
- материал трансплантата (предпочтение отдается собственной вене);
- состояние артерий голени, к которым прикреплен анастомоз.
После проведения шунтирования и послеоперационного восстановления облегчается боль, улучшается способность к передвижению. Часто удается отдалить срок перехода болезни в тяжелую форму и ампутации конечности. Для многих пациентов с тяжелыми болезнями периферических артерий шунтирование — наиболее эффективное и надежное из решений.
Возникает облитерирующий эндартериит у курильщиков, при обморожении, а также при работе с токсинами. Симптомы — боль в нижних конечностях, перемежающаяся хромота и другие. Только ранняя диагностика сосудов поможет избежать гангрены и оперативного лечения.
Закупорка сосудов на ногах возникает из-за образования сгустка или тромба. Лечение будет назначено в зависимости от того, где произошло сужение просвета.
Проводится операция на бедренной артерии при угрозе жизни из-за тромба, эмбола, бляшки. Процедура профундопластика может быть проведена разными способами. После вмешательства человек остается в стационаре.
Операция по шунтированию сосудов сердца довольно дорогостоящая, но помогает качественно улучшить жизнь пациенту. Как делают шунтирование сосудов сердца? Осложнения после АКШ и МКШ. Виды шунтов, что такое интракоронарный. Операция на открытом сердце. Сколько раз можно делать. Сколько живут после. Период нахождения в больнице. Как делают при инфаркте.
В некоторых ситуациях протезирование артерий может спасти жизнь, а их пластика — предотвратить тяжелые осложнения многих заболеваний. Может быть выполнено протезирование сонной, бедренной артерии.
Проводится МСКТ артерий нижних конечностей при подозрении на их изменения, после операции. Может быть выполнена совместно с ангиографией с контрастированием для сосудов ног, брюшной аорты.
Проводится реконструкция сосудов после их разрыва, травмы, при образовании тромбов и т. д. Операции на сосудах довольно сложные и опасные, требуют высокой квалификации хирурга.
Для предотвращения повторного инсульта, при повышенном давлении и прочих проблемах с артериями рекомендуется выполнить стентирование сосудов мозга. Зачастую операция существенно повышает качество жизни.
Необходимо шунтирование сосудов головного мозга при тяжелых нарушениях кровообращения, особенно после инсульта. Последствия могут ухудшить состояния пациента без соблюдения периода реабилитации.
Поражение и омертвение пальцев или мягких тканей после гангрены, требует обязательного закрытия сложных ран. Несмотря на восстановление кровотока у этих пациентов нередко остаются тяжелые пролежни в области пяток, голени, некрозы стопы. В ряде случаев достаточно простых пластических методов, но опорные поверхности требуют пересадки очень сложных лоскутов на сосудистой ножке. Наши хирурги с успехом применяют эти методы у самых сложных больных.
Уникальная микрохирургия сосудов при гангрене!
Консультации сосудистого хирурга
Москва, Ленинский проспект д. 102 (метро Проспект Вернадского)
Записаться на прием
Вопросы-ответы
Добрый день! Близкому мне человеку установили стенды в обеих сонных артериях. Это было в пятницу. Сегодня понедельник. Дышать ему стало легко, но страшная слабость, пальцем пошевелить нет сил, аппетит.
Ответ: Добрый день. Силы не должны исчезнуть. Обратите внимание на это лечащего врача.
Гангрена головы лечение
добрый день！Существует ли гангрена головы？Т.к моему близкому человеку поставили диагноз гангрена головы. Как можно её вылечить？
Ответ: Добрый день. Нет такого понятия
Вы можете по фото сказать гангрена это или нет?
Ответ: Пришлите фото по почте Angioclinic@yandex.ru
Перелет при окклюзии позвоночной артерии
Добрый день! Моему отцу (60 лет, диабет 2 типа) врач несколько месяцев назад сообщил о вероятной окклюзии позвоночной артерии. Чтобы подтвердить диагноз нужно было ждать обследования, затем ждать результатов. Они.
Ответ: Пусть летит. Не волнуйтесь.
Гангрена четвёртого пальца
Здравствуйте, у моего отца ампутирована правая нога выше колена из-за сахарного диабета. Сейчас на левой ноге началась гангрена четвёртого пальца и начала переходить на стопу и мизинец. Мы из Казахстана.
Ответ: Добрый день. Пришлите фото ноги в нескольких проекциях и данные исследования сосудов ноги (УЗИ, артериография, КТ-ангиография артерий ноги) по электронной почте Angioclinic@yandex.ru
лечение диабетической стопы
Мужу сделана пересадка кожи на стопу после операции по удалению мизинца при диагнозе диабетическая стопа , СД 2 типа. Вопрос- что можно посоветовать для быстрейшего заживления раны — пока наложена.
Ответ: Сложно ответить не зная состояния кровообращения и вида раны. Пришлите данные обследования и фотографии ноги в разделе переписки с доктором.
закупорка сонной артерии 100%
что делать, как быть,и что можно ожидать в такой ситуации,с уважением Николай.
Ответ: С этим уже ничего не сделаешь. Если есть проблемы с другой сонной артерией, то желательно их устранить.
удаление бляшек на сонной артерии.и удаление S- образного изгиба
После операции через2 дня сделали ЦДС, при осмотре обнаружили 100% закупорку артерии,вопрос- возможен ли в дальнейшем инсульт или смерть?
Ответ: Основные проявления острой закупорки сонной артерии происходят в первые дни
" недели назад проводили ангиографию внутренних и наружных сонных артерий.Рентгеноэндоваскулярная окклюзия мальформации левой половины лица.Сделала тест на берем-ть-результ.полож.На момент операции примерно было 2 недели.Я не знала о беременности.Переживаю о последствиях.Как.
Ответ: если облучения органов малого таза не было, вероятность влияния на плод и на беременность стремятся к нулю
Операция на артерию нижних конечностей.
Добрый день! Можно у вас сделать операцию на артерию нижних конечностей по ОМС? Прописка Волгоградская область.
Ответ: Добрый день! В настоящий момент операцию по полису ОМС в нашей клинике могут получить жители Московской области. Жители других регионов могут обратиться за оказанием специализированной медицинской помощи либо по месту.
© 2007-2019. Инновационный сосудистый центр — сосудистая хирургия нового уровня
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