De retroperitoneale benadering van de aorta en grote bekkenarteriën en een methode ter desobliteratie van het aorto-iliacale trajekt : beschouwingen over de retroperitoneale benadering van de distale aorta abdominalis en diens hoofdvertakkingen met
bespreking van de desobliteratie van het aorto-iliaco- femorale trajekt volgens LeVeen
Citation for published version (APA):
Widdershoven, G. M. J., & Willekens, F. G. J. (1981). De retroperitoneale benadering van de aorta en grote bekkenarteriën en een methode ter desobliteratie van het aorto-iliacale trajekt : beschouwingen over de retroperitoneale benadering van de distale aorta abdominalis en diens hoofdvertakkingen met
bespreking van de desobliteratie van het aorto-iliaco-femorale trajekt volgens LeVeen. [Doctoral Thesis, Maastricht University]. Rijksuniversiteit Limburg.
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Published: 01/01/1981
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1n J I L , In vercnlgnng gesclircven pracfhchnfit zljn lwee belangrtjke aspecten In dz arlcncle rc~ionstruclieve ch~rusgle mct belrckklng rot her aorta-lliacalc \laat-
irajckl onderzocht
I n clccl I wordt cle Rctropcr~tonealc benzaderlng van het a o r t o - ~ l ~ a c a l e toajckt besprnken aan de hand van dc dadrowel. bcst,landc gegevens u ~ t dl: I~tcratuur Middels elgelr wnderzoek werden d e voor- en nadelcn van d e R e t r ~ p e r i t o n e ~ l l e bcnaderlng vergclekcn me1 dle van d e Tran6perltoneak b c ~ ~ a d c r i n g van Pael a o r t o - ~ l ~ a c a l e ~rk~jckt.
B-lcr u n d e r r o d belrelst de bes~udernng van cell vrrlwel ~dentlekc. groep patlen- teal dlc dccls Rctro- en deels Transper~taneaal ~ c r d c n geopcreerJ In her Krankcnhi~us der Stailt-Wren-Laln~ te Welien en .\i,in d e grocp patlenten dle rllet ~clciil~ck Rctro- clr Transpentoiicanl werdcn gcopcrcerd ti. Slu~bkrl 14c r c ~ u l t ~ ~ t c n v ~ t n hct c ~ n d e r ~ u c k te Wenen. roali weergegcven In IiooSci~tuk 2 war1 deel 1 v,ln dot p ~ ~ c f i c h r ~ f l hewc..;tigcn clc gcgcacnis u ~ t dc Irteratuur en riln bewlj~end voor I ~ c t li'rl dat d c IFelsoperntoncale benadering vc.1~. voordelcn
btedi I o.v d c trria~~pcr1t~rncaIc hcnaderung, doc Inlet nzterdere c u r r r p l ~ c ~ ~ t i ~ ~ eeplra~ J gailk
Nd, b e j p ~ e k ~ n g van dc ~inarurnle \ a n dc antero- laxcrale buukwand cn her s p a k ~ ~ ~ m relroperuilonaeale, wcrrden enngc teclin~sclzc dcrdlls van hct Retrapento- nc,~,lU operesen bccprokcri cn clc ~ n r i a n ~ c n v ~ n benadering beiclirszrra. H ~ c r -
c i c w r word1 d~11i1clqk geriia,zkk d'lt \ n~j\vcl clkt. \arm van arteraele seconirrucclc aan he1 atrrto-iliilcnle tr;rgekt lalags E<etroper~toncnle n e g h , ~ m gc\chreclcn I3e E . C S L I ~ ~ ; I ~ ~ I I t a n hei p a t l h t c n n,~-onclcr/ock LC WCIICBI CII S l u n ~ k ~ l un tota'll
~espcc'xievel~.jk B 37 Relro- en 102 Trnnsperiloneale irpcrnL~es wordeia a l \ Rerm- en 1 rancgroep wcrgelzkcn.
N:L elirnun;utlc van cnisc ('actol.cn clue nlei 111 L ~ ~ [ T ~ ~ I ~ L I kutincrl uorden g e b r ~ c h t
~ n c l cle h e 1 i a d e r 1 1 1 g ~ w i ~ 7 ~ . u o r d t d ~ ~ i d e l ~ j k dat cr vele vcr~wli~llcn 7!ln h11 P A -
~ U L S I I ~ C " I I ~ < C I I . O - o E ' T ~ ; ~ ~ I ~ ~ ~ ~ ~ I I o I I c , ~ ~ I ~ C O ~ C I . C O I . C I
13u g ~ n o l $ i e vc~scliille~r I i j n cl~c \l,tta dc post~11-7~1.11nc~c c"on-~pI~c,~tii'\ ;I]\ 1 0 1 i y 1 1 -
I'cckie, cli~rulpns;~lysc (nlcu\) cn \lic)lldiiaar nl\sela [~nfecllc cn P I t t ~ ~ I ~ ; ~ t ~ c t i ) rlc cclmpl~cut~cs. Lomen b~g ~ l c Re~rop~'r~iclrrcaIe Ixn;ide'r~n~g Ihcd111~Jen1d m ~ n d c r
Vrlc'lr d,rn bkj d c T r , l n ~ l > u ~ ~ l i o [ i c ~ ~ l ~ b c ~ i ~ i d c ~ ~ i i g , w a n r b ~ j dc/e co~lipllc~tlles \ ; ~ k c r n n n l c ~ t i ~ n g gcvcli ~ c ) t ccn I e t ~ d l hcli~t3p voor 1Ic P ~ ~ I I C I I ~
D c ~ o I . c ~ ; B ~ hct a , l n ~ ~ l I co~iapluc~ii~cs, 3.5 \. / o wclnlg I $ 111 de Kc~rogsoel.r ,rls rn clc
* "
I r;tn\groep \ \ o r ~ l t de 11101brtlutc1l \:an Jc p,tlicriccn In tlc Kenrogroc]~ gunzbig h c ~ n i loecl
C e m ~ d d c l d e opcrnl~ccluur I \ iZlaor. d c lictrogl.ocp "2 utrr korker i l ~ n voor dc - l ' ~ ~ ~ n \ y o c ' p . 1erwqpU llct gc~niddclcJc l.rIoed~r"t.b~ii~k 111 de l.ransgroep 500 ml l ~ a g e r i\ clan l n cle lietrogroep.
Parlenten lnlt d e Relrogroep verb11~li.t.n gen~lddeld 3 A 4 d ~ e e n korler In her 7aekenlruls (postopesatlc0 dsln In d e l'r;tnrgroep, ulaar 80% v a n het i~untal geopereesde paitlenten langer dan twee weken I n lqct arekcnl~uih vcrblqii.
Als gevolg van d e gunslige re\ultaten en her ~plolter belaop bnj de Retrnpcrlru- neail geopcreerde patlenten klnnncn wid concluderen. dat de Re~roperiiolic;ale bennderbng voor patientell niet arheroscleroln~che afivijklnge~~ 111 het ;rc)rto- rhacalc tr-rqeke dierir te wordcn aanbevolrn.
In deel 1 1 van het proerschrifn word! de desobllteratie nrethoiie, ontwlkkcld d o a r LeVeen, m.b.v. diens guillotine, (plaque cracker), bescl?se\i~en en hez rejultaal v a n dere desobliterane methode crnrierrocli~r blj 70 patiknfen dje 79 operaties s n d e r g ~ n g e n In her Veterans Administsailon Ho5pltal tr Brooklyn, New "fork er-merrijds en h11 45 in Slul&il geo~-merecrde patlllin~ten andcrzrjds.
VooraVgaarrde a m lret eigen ondcrzoek ti- New York en Sluiskil, vl~orctr ~ r r hoofdstuk 1 van decl 113 d r problemaiiek de operatwve reoon5truclae v a n
k t aorro-~llacalle tralekl de Iinnd van een ultvoeng I I ~ C ~ ~ ~ E Y L ~ I O I I ~ ~ I . T O C ~ brsproken levells worden in dit hocbfclstuk d e nwce st~tnidaarJtcchn~eEten \:in
uperatlc, rijnde desoblhteratie en bypass nader b~"sch~3uwd. Voor- en nadelen van b e ~ d e techniekcn warden ann d e hand van literanu~~irgegeven~ beschrrven en aan cie hand van de eigerl res~lltaten becornnmclltaneerd.
Ivn het eigen onderlock valt o p clnt xo\tel d e vroegc als late rccmlrale~~ iell gnnsle van1 de desoblltcratir la~t\,dllen; reden liwanronl w i ~ 11-1 dit r ) r ~ c l x l ~ r ~ f l dc dew- b l i ~ e r a ~ i e tvillen aathbevelen
In hoolilstuk 2 v a n deel I1 word[ d e c>ntwlkkcling van de guillotine c a n LeVeen heschreven Vcrorzs wordn de tcchn~ek aia.b.\. d ~ t rn\trtlnacnl ultvoerig he5lxo- ken en de varmen van coepabsrng L I I ~ C C I ~ ~ ~ L ~ L . AIs contr;~-1nc1ic;ltw voor llez g~%ruik van de guillat~ne worden1 genoernei: ovcrnlatrge locale kalk;rlictting rn d e ~ i t ; ~ t \ h ~ i ~ ~ ~ d . en cle ornvnng van het te desobliteren \'a[. ( k l e ~ n c vateta rz1.s ,]I tcrlrl
fernoralis profitnda). Teveals wordt d e nperatletechn~ck bescbreven vnor he1 ..Z eidge I~jtlcl~". (aorlo-ili~co-fcmorClIe de.soE~l~ri:~.;tllc), die rnel h c h ~ ~ l p v i ~ n tlc guullotlne V J I I l.clieen in comb~n:lilc. nlet tie ringslruppcr u,rn ktollln;~r YI\'III.LII
LI rtgevncrd
klooTclsti~k 3 varr deel I 1 bevnt licr elgel1 crncierzock 1-lrcrln uordcn clc I L . \ L L I I ~ I - Len zowcl voor New York ais \iroor Sltnlskrl wcergcgeven. Dc 'early- patcncv mnre' rn New York bedratigt 97.5'1; drc van Slu14.1l lQ04 13c ‘laic paterrcy rate" 1s ti(301. New 'fork nn 5 jaar XY(Y en \'oar S I L I P \ ~ I I II:I 3 J I I E I ~ 11og steeds UC30'1:
Air, Irocge complicatre werd In N C W York ZX ern vrocpc ~'e-lhrclr~vbo~ca'rnrg gerlcn I g i klc.pvorrn~i~g. tla jc-l~rtericnt~e kon d,it euvcl E ~ I J btt~cle pblilcnicri uurden \~erholprn Bij clc ]-iat~enLcn u r i Slur411 werd re-cxclui~l: 1.g v rntllnn
klepvor~nro~g lilel wd,lrgcnc,ll~cn. zclwlll Ix ccn I > I c ) L " c I I ~ ~ 111 de homolrltcr;~le
arlcrla llldca cxlernd oplrad na her, p e h r u ~ k van d e gu~llotine Dere b l o e d ~ n g weld m ~ d d e l s een ro-sn~crvcnltr vermrgd
Lcztc complncnlic\ werclcn rn Slu~ikll ilret haargenornrn, rerwql ~ n - N e w York b ~ n n z n 3 -5 jaar 9x cen re-ucclus~c. optrad.
I n dqel I 1 1 van deze dlizei'ndtle hordt d e stesabl~rerat~e wolgens LeVecn van h e 1
carl lo-iliacaie (-fen~oraIe) rrdjekt Iangs rerropenioneale weg beschrewen.
, 4 a n clc 11;incl van ccn rotoscporlage werrdr d s operahe teclinlck 'srep by btep' gctonr~d tcrw~jI In hct cigcn o n d e r ~ a e k d e sesultatelr van d e operatle ultge- voerd In New York en In Slu~skrl wordcn weergegeven.
De operarle rterfle rn New York is 6$%? In Sluiskil4,4%. Pre-exs~stent Injclen.
apehatie type en comphcatres worden vesncvernd
J e l t h ~ s , jointly writtern t h e ~ i s , two i m p o r t a ~ ~ t aspecxs of reconsSrucllrre artrrlal
\urgrry of the aorto-ll~ac rcglon are descr~bcd.
In Part I t1.r~ re~roprriioncal approach tr> the aorro-~iinc area de~crilned and t l x relevant Iitrrirturc is sev~ewed. U h ~ n g our oun rnacerraii tile :1~jl:lllt3g~b ,UYJ d~sadvar~nages af the rerroprr-laoneal appm-oacl~ are canipared ~ ' 1 ~ 1 1 1110le of the t r a n s ~ e r ~ t o n e t t l aglxoach to (lie aarto-ili,lc ‘ires. Our mater~dl u '1s corlaposed 01' tk\o s11m11ar groug~i o f p a l l e ~ l ~ s VIJIZ(P had retro- and tra~-~sl>rr~toncnI e.kplr.rrat~ons an the Krankenh,~ub der Stadt-E."jie~~-La~~iz 111 Vienna, and tuo d ~ s s i m ~ l a r gn)ups of palcnts. who had the i a m r opercJtrons 113 SIu~bkil.
T h e ~ciult., of the iniest~pation i r ~ Viennd, ~ I ~ u c h arc g ~ v e r ~ in chapler 2. Part I, confirm the reports In the illeraaure t h a t 2/10 rctr013crilor1eaI i ~ [ y ) r ~ t h ~ ! i hi14 IRi117)
aclvantage., over [Ire tra~ispcri~oneali approach IIN w h ~ c h . for evarnple, tlacre arc more corn pliualions.
The anatomy of the antero-laleral abdomimial wall 1s described cogetlicr with techn~cal details or' the ~.et~o]>eratonei-rl operaticlo dnci possible \faruntions In the a p p r c x ~ c l ~ thereto. I t 15 clearly e v ~ d e n i lh91 i ~ l i ~ ~ t ) \ t c'rferj forla? ~ S ~ t r l e r i a l recon-
ctruc~iori In the aorto-111nc are;) can he d o n e by 1iic;uns of the r e l r ~ p ~ r i t i > ~ ~ c , ~ l approach.
. E
.
he result< of ~ h c opcrdrrons carrlecl out in V ~ e n n ~ ~ a n d S I L ~ L ~ ~ I I total 137 ~-ctro-
;rnJ 102 rr;iu~\per.itoneal o p e r a t ~ o ~ z r . are coraig7arcd ~ i r ~ d e r thew Xwo ~ ~ r l e g c ~ r i e s . Al'ter ilillowancc 1s ni~ade for other Sactor\ IIC)I ~.clc?te~J 10 [lac naezhocl of .surg~c:ll , ~ p p r x ~ ~ t c l ~ , i t i b clear that there are i~iipnro~lnt d~lf1'esca1cc.j in t l ~ c two g r i ~ ~ ~ p s 011
rclro- and tran>perizoneall),.
T h e b i ~ g e s t d ~ f l i r e n c c l r In thc lncitlc~ncc ol'poitupcral~ve c o r n p l ~ c ~ ~ t l o l a ~ , ~ ~ n o l i a\ pi.reunlonla, partmi! t ~ c ~ l c u s ;mid w o ~ ~ n d conipl~catro~is (~nlfect~ons a n d dcli~s- ccncc) T h t a e cornpllc:z~ir3lrz arc 111o1.c II.L"C~UCUI~E~CP 111 t h ~ Tra~i\pcrrtcane,ll group
~ t l d oflelr Ciin be LitaW for thc 17;ltlcnfi. l'hr mtrrbrelurv of p i ~ t ~ c n t s 111 t l ~ c roll-o- p s r ~ t o n c ~ r l gn.c_,i~p I, rn~~ich I C " ~ , ii11d [lac. ~ I I U ~ Y I - J ~ I O ~ ' P ~ ~ Z O ~ C I . ; I I I Y ~ ctannpI~c;l(lo~~i 1%
one- tlibrd that o f p;rnlcn[s in ~ h c : I ' r , l ~ ~ s p c r ~ ~ o n c a [ g r ~ ~ ~ p . *I'lie aterage (~oiii: 01 opt.r,lalon wai, 1r;ilf ,ln hour shorter Ibr ~m[urnt.~ In [lie R s ~ r o l ~ c . r . i t c ~ n d gr01117
~ o l d l l ~ r averagc amoulal of blood t~;~rrjf'us~on given W C I ~ 500 1n1. I c i i I.";lllenI$ i n
the Transprritonealrtau 83 rclraa~ncd a n average or ~Iirce lo fcrnr day., lon~gcr In hosp~tal a ~ z d SOY were Inore than t w o weck.; 111 the Iiosp~lai.
Aa .I rc5ult o f the l.llr,re i''lroi~r~tbUe lindrngs and the ~noln-c r.,lpltl ruLo\'cry nf 1 8 1 ~
Renroperrkoneal group or ~ ~ I ~ I C I I ~ S . WL: c o n ~ l u d ~ d f l ~ i ~ i l the rtctroper~loncal np- pro~c11 C ~ L I I be I C C ~ E ~ I ~ ~ L L I ~ ~ C ~ f i r pal~cnts w110-1 a~hcrosclorc~tl~c drseGlw 111 the I ~ C ) ~ ~ I I - I I O , I C ,Ii.ca
In, Part I I of thc the513 the dcioblltei;~i~ve rnerl~odl of LeVeen (the so-callcd gwlllo[~nc rsr plaqut cracker me~hoci) 14 Clescrubed and rhc resuPlz u\iaug ihri
mctl~od are descrthed In 70 pallenti vlho underwent 79 nperafflcrns at the Vclcrans kdn.r!ni\lral~on Slosprcal rn Brooklyn. New York. and ~ r r 4 j parlent\
operated In Sl~114kll
I n chapter 1 of Pnrl I I [he probJems of the operative reconstruction a l the aor!o-~li,lc area are described l d k r l a g 11ito account the relevant 11ter;tturc T h e
iwej standard ~cchoiiyues o f opcr;ltlon (namely desobllteratlve i ~ ~ t f bypass) hare
cons~clercd in n-rore delatl. The ad\ anrages ,~nd dtsadvanrnges of both technl- q uof arc corripdrcd wring our own a n d other peoples results.
Our o w n 1'1'5tu31~ 5l10w that both 11.1 the jlrort and long term rlicre are ndvant'zcs
117 the eleiobllnturaerwe nechnig~~c. and thu\ we recornmand this tectinlque 111 t h ~ i thesli
111 chi~later 2 of piti-i I 1 i l ~ e dcwcloprnent o f t h e gu~llotine rnslsunzelat of LcVeen
I \ clcscrrbed, together wlth 11s nlell~od ol ilsc a n d appl~cations Among contra- rnclicailon~ of the use ol'iucll a gunllot~nre has been rnentloned tllc prercncu of cxce\slve ci~lc~!?chalaon In 1he arterial wall and nhc fact that I e cannot be used nn
~ni;ill artcricc s~1cl-1 as the dccp femoral arterl In i1i1c t h c s ~ s the operallor'l tcch~slquc is also dcscr~bed for tlie two m g e r aorto- ~luac-l'emor~~l dcioblrtera-
I I Q I I zrvI11cl-a was carr~cd nil1 usrng [he LcVeen gulllarlne and i l ~ e Ycrllr-nnl- rings-
11 lppzr
.
Chapter 3 of Part 1I contams our own findings a n d the results arc givcr~ for the New Yurk e n Sli1i5litl group of patients. 7'he'eL~rI~-pateiacj rate' In the New York group wil> 97.5%. dnJ IQOY, for tla:it In Slu~ckll. Thc 'late patency nrtc' for [he New York group (after 5 ycnrs) \ . a \ 898. a n d for h a t o r Slunskil (after 3 years) was h t u l l 1008.
In New York two cascs of early rethrol-nbosus occured as n result of valve forni~ng. anel I n hot11 casts this was cured at rc-opcr:~llon No cases 111 S l ~ ~ r s k t l clcvclopcd rcoccluc~on ~ 1 4 < I resi111 (31' valve rbirn-r~ng. but nnc pai1cn1i 11,1d Il,it.- mol ~li,rge 111 the extcr~ial 1lr;tc artery on t h o same s~tie, ,%s a rchult of the use ol the g~nllotrne. O'h~s blcedlng w a s treated b! reoperatLon
Olcre wcrc no I'ztc conapl~cat~orrs In Slu~\kul, but 111 thc Neu York grnlrp h e r e wcr'c 9 c a w c-rl'rc-occlusio~a over the ti7llowrng 5 yerrrl.
I n p'lrr IBI disobl~tcrra~ton oT the irorto-~l~ac region 1s dcscr~bed u s ~ n g 1l1e nuiro-
~ ~ C Y ~ ~ I I I L " ~ ~ I ;~l>lal.o;lch 83y I I I L ' ~ I I $ 01' plrotographs cl 'step hy itcp' de\crlbt~on of' the op~'r;t11011 I \ gllen. ,~ncl the re\ults of the openatron cal.r~cd our in N e ~ v Ynrk and Sluisknl ;lrc s l ~ o w n .
1 lac trpcratl!c 111orna111) In NewYork vrl,~s b 3% < ~ n d i n Sluask~l 4.49.
TYIC zncidcnct. lot'jareog>crnti\e ~ 1 1 > ~ i t \ t : ancl sylnptoms, the eutenslucnesc of'thc oper:lnloll\ and the c o ~ i ~ p l i c ~ ~ ~ ~ o n h Lbllowrlig are critucdlly e ~ ~ i m ~ ~ a e d .
Conclusions
In concluszon w e e'stlmmate.
1. Disoblrterat~on using thlc LcVeen gu~llotnnc hi]? a justlfi3blr j31ii~t' I I " ~ I I C D epcxd~lve t e c l ~ n ~ q i i ~ s a\.allitbl~ for rcconstructl\ls ( ~ r t e r ~ : ~ l curgwy.
2 . T h e retroperlroneal approach Ibr disedsrs of' the aorio il~ac direas 11:~s ad- vantages over the transperitonean approach.
3. Drsoblileration vsirrg the LeWecui method land the retroperi~oncal ,ipproach provide a U ~ C F L I I itddl~t~on to recolz~truc~ive artcri,iI Fzlrgery, provided [hot the ctand~tions d e t a ~ l e d in t h i s tl~esis are pnjperlj '~dtlered to
4. Aorto-~liac-fs~~noriul arteri;rl disease. using [he methods dcwrlbed here, can be succesCully c a r r ~ e d clut in a m a l l , properly equiped peripl~erlll Iro>pr{al.
In daescr- gemcrl-rsarn gsschr~rbenen Dlazcrtatron werdsn 7 ~ x 1 wcsentluche Kr- rerche dcr rckonstrukzlten Astcricnchtrus-gie des aorzcp-~llakalen Atacchnlttes bearbelnet
In 'Tell 1 wprd der relrapcr~toneale Zugang u r n aorta-rl~akalen Berelch be- schuiebci~ w ~ ~ c l eln entsprechender Lrteraturiiberbl~ck dazu gcgeben. In Bear- bentung unserc% elgcncn Palucntengutes wierclen dre Warte~le und N,icl.llellc d e i setroperitorrealen Zuganges zur aorto-lllakalcn Gefassstrecke vergl~chen Das Pallentengim~ s e k t vch aus LWEI Srhnllchen Gruppen zusarnrnen, die irn Krankcnhaus dcr SlaJt Wien-Lainz retro- odes traniper~tone,~L operrert W L I I - den, ~ l n d zwci nicht verglc~chbdren Palict~tcngrilpperr. drr n ~ i ~ t r l t glrbuher Zugangc I N S I ~ r s k ~ l operserL wurdcn
I31e Ergebn~$ce d e r Unterst~ctlungcn In W ~ e n , die rn K a p ~ t e l 2, Ten1 I dargelcgcl werderr, bcrlanlgcrr elre Lrtcrati~rangahcn. das\ der rctropcrutonk~lle Zug,lng zahlrclchc Vorroulc gcgcnuhcr clrern tran\perutoncdIen Zugang ~ e i g t . bei btel- chcnrr ~ u n ~ ~Jc14prei ~ 1 1 1 ' K o ~ ~ ~ p [ ~ k d l l ~ n s l i l ( e hoher 11egt.
Die Anatonlhc Aer dn~ero-luleralcn B~~i~cl~uv:inel urrd rLl~alnmen IIIIL den tech- ntscllcrr Ucnails d s j rc.tropcrrno~icalcn Zugalage5 i111d scrnen rn6gl1chen V Z ~ S I ~ - nlonen besclisiebcn T.s 1,1sst slch kll'ir lierau+stcllen. class l h s k ledc aorta-~lnzukalc A r z c r ~ c ~ ~ r e k l o n ~ t r u k l r o n 11111 O-IIITc de.i rctroper~tonralcn Zugmr,grs durcl~gcfuhrr wercJcn kann
LSre Ergebn~lsc der 137 rciro- ~ l n d 102 tr;ilnspes~torie,~lcn E~ngrrSfc. d l r 111 Wlen uu~d S l ~ r i s k ~ l durchger~lhrr w ~ r r d c n , wcrdcn rz~lterruanadcr vcrgllsuhcn Nacl~l Aus- sohalturrg von I aklorel~, d ~ e n~icht In Z u ~ a m ~ i ~ e n U ~ a n ~ g nnnt der h r l des clilrwrgu-
\chcn Zugangsweges gebracht wcrdeu~ konnen, rclienrzl e i e\ndeari. d ~ i b e\ en[- zcl~eurlendc U n ~ c r s c h ~ c J c zzv~rchrn den G a ~ ~ p p e l i d e r trans- urrd rciroperuto-
neirlcn Y L E S ~ ; ~ I I ~ ~ W I . ' C I ~ C glbl I3rr pro4~11: L~nlcr~clzrecl l~cgt un'r Aut tlcten on po\ttrpcnd*Inlvieli Kompl1kn1uone1.p L V I C 1 3 ~ ~ c u ~ i l i ) ~ ~ ~ c , 1p,11~1I!11icher [ I t u s nlr~d
W u ~ i c l k o r n p l i k ~ ~ ~ ~ o t ~ c ~ ~ i r-rzut lok,tler W u r ~ c l r n ~ L ~ r c ~ r ~ trnd I ~ t i n i . 1 ~ 8 c . l z r s ~ c 1 ~ ~ ~ 1 1 T'l~ese Knmplnknr~ai-ren nlrr oft 'lf;~r,~lem \ifcrI1l~f t r c t ~ ~ n ;~113~11'1 111 dcr- ~ ~ I L I Y \ ~ C I I - loncal olperlcrtelr IDdt~e~rtengruppc iu~~l.. Due po\!opcr,rtl\e hilor hld~ll:lt In der
r c ~ r o l ~ c s ~ ~ n ~ i z l l c r ~ Grtlppc niut den obunr ~ n g c f u h r t e n ~ . O I ~ ~ J ~ I ~ , I I I C ~ I Y L ' I I 11111 I i
~ C I . I ~ I ~ C ~ ,)I\ I I L L C I I ~ ~ ~ : I ~ I ~ ~ ~ T I ~ O I I ~ ~ I I ~ I ~ I Z L I ~ ~ I ~ I ~
I31c rlilrrchscI~n~~~I~clic O p c ~ ~ ~ t r o n s d a ~ ~ c ' r rsl 111 tlcr sc~rapzrrtone,rlcn G r u p p c una c ~ l l c hnlhr. S E L I I I ~ C kunfcr, cben\cc ~ u r d e be1 dnetcr Gruppe In1 Mrttel 500 rirl uclalgcl B j l t ~ l tl;ln$lirndrel-t. Parlcrrlci~ d e ~ t ~ c t ~ i \ ~ > r ~ . i t O ~ l t ' i i I e i l Gruppe \Irrlrsen elr1c.m 3-3 '1 , ~ g c I;ullgc.rcsi Kr,tr~kc~1haus,~u1_c11tI~~1l1 , I ~ I ~ ' L I I I ~ 80% ~ i ~ c c e r P,itie!nlen
area? I:~iigc'r J I ~ 2 LVocIicni I ~ o s p ~ t ; ~ I t \ ~ e a t
Als Ergebnis der besseren postoperativen Befunde und der dcritlrch n i d e r e r r posaopesatiwem NormaP~sierung muss der rerroperitoncale Zupmg zur 13e11e-
bung vcsn asterloskilerotischen Laesionen des aor'to-iliaktllen ( J n e f ~ i s s ; ~ h s c l ~ ~ n ~ t ~ e ~ ernpfohlen werden.
Lm Teil I1 dleser Dissertation wrrd die Desobliteratro~isrnetL~~~de nach LcVceni (Guillolune- oder Plaque-Cracker-Metllode) beschrleben. Dze Ergsbnasse die- ser Operax~onstechnik iverden arr Hand van Unier5uchungen an 70 Patlenten nmlt 79 salchen operatuven Eingriffen, die arla Veteran5 Adrn~n~strarion Elospl- tal, Brooklyn. und an 45 Patienten, d ~ e im Urankcrahdu.; S l u ~ s k ~ l operiert wtlrden, heschrleben.
Kapllel 1 , zeigt die Problerne der Rekonstrukticsnstechnikcn des amto-~1i:lkaIrc.n Abschnittes mnt einern en~spreelrendeni Litcraturikberblick ainf Die eLerzeit Ublichen Standard~echniken (Desobliteratiorrs~~erFi~hren und By-p:rsstechniik) wesden nrlher besprochen. Die Vor- und Nachbelle beider Techrzieker~ werdenl durch Auswertung der El-gebnmc des Krankengures l-re~der obig erccAhn2er Krankenhauser beschnebe~z. Unsere eigenen Esgebnisse zeigen in1 K I L I ~ E - und Langzertergehrnis die Vortcilr: der D e s o b l i ~ e r a t ~ o n j t c c h ~ ~ ~ ~ k . Dies veranlas\t u n \ . diese Tcchnik irn be5ozlderen zu empfel-rlen.
In Kapitel 2, wird die Enrwicklrung des "'Cj~~illotine"-Ensirutne~ars nacl-n k.cVccn be5chrieben sowie scirn Gebrauch u ~ ~ c l seine Anwendung. Unter den Kon- traind~kationen des Ein?at/.cs d ~ e s e r "Gubllotnne'herden ausgcrpr:~gte VcrkaU- kungen der Gefasswand gcnannt scrwie clle Tatsache. dass die\es Inctrument an kleinkalibrigen .4r~erten wic der Arlcria fernoralis profi~izda n~oErt angcwenclcl werden kann. 111 claeser Arbeil w ~ r d el?enljlls die Zwcietagcnde\oblitera~1(211 aorto-~liako-femoral beschrneben. die in Kombination mnt der LeVecn GLIIIIO-
ti11 und den1 Volln-rar'schen Ril-rgslr~ppcr durchgefiihrl wlsd.
FCap~tcI 3. bc~nhallet unsere eigenen ErF,ahrungen owr re ~ I L ' K ~ ~ r z ~ , e ~ ~ r e ~ ~ ~ l t i ~ t e dcr Pat~errrengruppe aus New York urid Slu~rkil
131c "early palcncy rate" In der N c u Yorker G r u p p t LwtrLig~ 97.5Y. die clcr Sluiskil G r u p p e IOO(ih. Die "late-patency rate" ;Ills Ncw York ( 5 - Jal~resrrgebnis) lnegt bei 89% und au\ Sl~~r\kzl (3-Jahrc~c'rgcbnn\) bci IOED9i2 Zwelmal kana es in dcr Yorker G r u p p c ~u Friihtlirornhoscn ,ki~r'C;rund vorr n o t ~ i e r d c n dislaUe11 Intlnra\kulerr, die dwrch Reoperation rc.p:krlcl.rt werden konnten. In der clgenen EPaz~cntcngruppe i n Sluu.skiI tra t k e ~ ~ v c I 'r~ihtlirom brrse auf. ;~llerdingc e ~ n m a l elno Rlut~ng $uu\ clcr Alterla i l l i 1 ~ 3 exlerna dcr honzol;~- teralen Se~re. welcho n i ~ f d ~ e Yerwcndilng der Gu~llollnc ~ ~ ~ r i j c k r i r r u l ~ r c n W ~ I . Spatkoiliplika~lonen zraIen jn der Sl~ioskll Crrupl?c, rm Ciegcn\ao LIT NTH' Yorh Grrnppvt r n l t 8 KeverschlLis\cn 111 J e r erstcn 5-dnhre.rperiode niclat auE:
In T c ~ l I I I w ~ r d die ; ~ ~ r l o - d l d k a l e Dccobliteratl~n auf retroper~toncalem Wege dargerrellt M11 H11k photcagrdphischcr Dokunlennat~nri w i d schrzttwe~se die Oiperat~ion bewhrichen Die Esgebnisse dcr Operationerr aus New York uncl Slu~~liikrl werdcn verglrchcn. D I P O p e r a r ~ o n s r n o r t a l ~ l a ~ In New York betragt 6,3%, d ~ e In Slulskll 4.4%
Due praooperalrive Plusgangss~twareon, das Operaitions\iierfahren slewie die jle- we~ligen Kornplrkaalonen werden krlrlsch beleuchtet.
I Dic De\oblitcratrnn rniltels d r r LeVecn'schen Gulllotin k a n n cnncn be- sechtigten Platz urlter den verschredenen Oprrat~onstechniken zus Gefhss- chirurgischen Bchandlung der arterioscler~tnschen licrschlusskrankheit cinnchmen.
2. Uer rerlropcritoncale Z ~ ~ g a n g zur aorto-~llakalen Ccfassslrccke zelgt eln- cleurlge Vorlcnle gege11t.i her dcrlr ~ran\perltionealen Zugang.
3. Die LsVccn'scbe D c \ o b l ~ r e r s ~ i o n im Kombination r n l t den1 rstropcritonea- Icn ZugG~llg crweltert Jar Spcktrum J r r rekon~truktiven GefAswhirurgie sinnvoll. D i e w Vorgchen w v d erstmalb e ~ n g c h c n d borgestellt
4. Erkl.ankwngcn det, aorto-iliako-fe~nwrzile~~ Gefrlssabschnittcs kniznen 17111 LZCF h e r vorgestelltesr Opcr~oiansrechnlk erfolgreich In kleineren, entspre- cllend ausgerii\letcn per.~phcrcn Krankenhguscrn durchgefbhrt werden.
D a n s celte thkse, h t t e en assaclatlon, nous avoni, C!uei~@ 2 dhpectc, Irnpoi.t,krl~s d e la cli~rurgre arnkriellc repasatr~ce. en rapport avec B'arnkrc aorto-il121que.
Dans la premiere parrlc nous dkcn\wns l'approche r e t r o p 6 n ~ o n i a l e du tr:ijer aorto-llllaque d'aprkc, les dcmnsrkcs de la Irtt&rdturc'. Notre trava11 pr1.~01111el .i p a a k sur ller avanrtases et dksavant,~ges d e I'approche rEtsopCr1to116ale en cornparaison avec I'approchr transpkritcrnCale. Nows n v a m 4tudlkb ~ C U X grou- pes d e patienils semblables q ~ i i f'urent op2rkb par v01er&trol3kr1toni'iI[C 2\11 par
L O ~ C transp2ritankale d 17lahpltal d e Vrenne ( K m n k c n h a ~ ~ s d e r Stadt Wten- Lr-11nz) ea deux groupes d e patientb r.utln selnblables operks
A
I'h8pil:iI d e Slu~akil 1-es rCsuYtt1ts dcs elcpkrlences de Viennc, o40nnl:b davls Ic chapitre :! cle la.prunikr-e partie d e celre tbviw, cunflrmrnt Its donnkes d e la lit[esnture el cl6nla1?tre1lt que Ihapproche ri"tropi.ritollthle ~lrksrnto h c a u c o ~ ~ p d'avat~t~lges pas rapport d l"approcll~e !ranspkncc~n2ale, qur s'accoi11p:ignc dl: plus d e ccrnn- plrcat Ions.
Aprks descriptron d r I'anatomlc d c la paror anrkrn-lurkralc ;rbdoi-nr~i~~ilt., ct d c I'espace rCtropCritonk~tl, nrous doilnons quclques dBtailla t e c l i n i q ~ ~ e s de I'opkr;l- tion rclrop2nlonkale el les vari~inres d c cezk spproche N o u s pouvons airlsi d6111ontrer q u e taute rsconstruc[ion rtrtkricllc du rrqjct aor~o-ullaquc peue se fklre par la vole ritropkritonkale
L e s rCsultan\ d ~ a Ibllow-up dcs p;ptients op&r&\ 2 V ~ e n n c ct 3 S l i ~ ~ s k l l . ( ~ r u total 137 op@rationflrClrop6n!o1ri.ale et 102 op6ralloo1s l.m17spCritorai':r\c'l) snnL c o n ~ p a r k s en tant clue grovpc "retro" cl ggt-oupe "nsans".
A p r & Slirninntlon cle, I'acte~~rs qui n'ont illrcllvn rapper-I nwcc I'approche. il drvrent kv~denn qu'll e x i ~ t c d e glandes dunl&rcnccs enlrc Ics de~rx'groupej Les plus ~ r ~ l ~ i ~ l l e \ dlff2rences portent sur lrs c o ~ ~ r p l ~ c a t ~ o n s post-oper:k?orres,
~clls:, clue I"infect1011 pulriiona~rc, I'deus p:rr;llyniquc, ~nfection rlc: 1'1nlcisiol-i cr Ic
"Plat/batlch" I-es complicat~ons son? main\ f r k q ~ ~ e n t t x , ~ p r & s I'apprc)cl~e rk- Iropi.ru/srn6aIc. D'ans I'apprc>chc t1-~1nrp?~.~lonC'L21e lei cc>nrpl~c~~lt~c$rrs O I I I uni pourcenataFe plus kIevL" d'l'isire ~ ~ I ; I I c VXI que U C nomhsc dc. ~ ~ I I I I ~ ~ I ~ ; I L I ~ O I I . ~ c \ I 3.5
i n.tc,lrlcJre d d n l le groupe "recrow ~ L I C d i l t ~ i le ~ ~ O V I I ) C " ~ ~ : 1 3 1 \ ' ' , 121 ~t)o~brdrLi. olan~;
Be groulae "rein-o"ee\t fa'a\.or:iblemcnt n~~flueneCc.
L'operation du groupe '"ctro" "re en m>oyclqnr uul~c J ~ I I I I - ~ I ~ u ~ ~ d e morn\ q u c celle du g r o ~ ~ p e "trans"'eet Ira.qunntrtk de $zing tran\ti~sC ~nl'krie~are tic 500 r ~ r l 5 celle du groupe "trans".
La J L I I O ~ dY.uo\prtal~\,ilrot~ dcrns 11: groupc " ' r r t r ~ ~ " ejt en nioyeiinc d c 3 {I 4 l o u r \ p l ~ ~ i courtc q ~ ~ e d a n i Ic. gronpe "ll.ans" J a n s leclircl 80% dc\ opC~.Cc sont Irohpl- eLtlisC\ clurtln~ pieis dc ilcux W ~ I ~ I I I C S
A L ~ V M dcir rt2suliari tkvordblc\ iubtenu\. L"I de% complncat~ons rnolndrc3 prC- scniCc5 par 1 0 4 pazlcn ts opCrke par vole r>tropPr~loaut.ale. n a u i poulbons conclurc yue B'approchr rklropkrntoniale rst a conseiller pour les pauents alleints d e coln]~!i~~ittlons ari@sroscierol~que du ts~qct Liorto-ll~:iyue
D ~ n s la deuxa@rne Partre de cettc [hi-yes. nouf dPcrlvon5 !a 1nCthode d e dkso- hrlllciralror-r, m i s t a u point par H. LeVecrr. aw rnoyen de aa gwillot~ne. (plaque cracker), el 1e.s skiullats d e cette tcclrn~que d a n s un groupc d c 70 paatents. q u ~ stlbirwni 79 opCrs;l~oni, clan3 le Veterans Administratian Huipilal de Brocvklvn
~ ' L I ~ C part, et dc 45 pat~cntc, opere'; pas nou" SIt~s~k!l d'autrr p a r t
Darrs Ic cl~apatre I de la douuci~nc parlie, nous ~ ~ C ~ I Y O S I \ d'apris les donntes abon~dantes d e la lir~t.riilure. ley pra;lla16mecA prCsentks par Ibcrgit.r~~r~om N u ~ l s
r,
d?crlvcpnr Cgalcnient Be4 deux t e c h n ~ q ~ i c s dkperations standariskes, cYe$t-a-dire la dCsobl11Cralion et la t e c h n ~ q ~ i c d e "by-pass" L e s avantages ci lcs dksavanla- gcc, des deux techniclucs solit d i c r ~ i e b d'apres Ics dono1Ct.s d e la iitli.rature ct celle) de nos rE.i~rlltaEs ptrsonnclq. Notre lravail dt.n.iontre q u e ile% ~LLsul~ats ininiCdiarc et lolnia~nc plaidclit cn faveur. d e 1,i desnblilkrarron, e'rst puurquai nous con%eillons dans cette th&e la rechnlque de la dC%c~bl~tCratiirn
L,c c h a p ~ t r u 2. Je la deuxikn~e partle d k c r ~ t le dkveloppenrent d r la g u ~ l i o ~ ~ n e d c LeVcc~a avec colmlnc conere-sndica~~on, la calc~llicarion exceshivc die !la parill v,t~cula~se.
En O L I ( ~ U , la g u ~ l l o ~ l n e dc LcQcei~, nc peur Stre uill~sC> dans les artkres d e fi~lble dia111elre tellcs que I'arlksc li-:rnonalc profo'onde.
N o ~ r s d e c r ~ ~ c ~ ~ z s Cgalenlenl la t t c h n ~ q u c o p c r a t o ~ r e en cns d e Ikbionc cler d c i ~ x Clage.s (dk.robl~tCrat~on aosno-~liacca-fk~~ior:~le), q u ~ cst et'kctui-e acu mnyon do l i ~ q l ~ ~ ~ l l o l i n e d c LeWcen en conrbinai\on avec la " n n g i t r ~ p p c r d c Vo111~111r*' Le ctzap~tre 3 d c la cleuxlknlc Partie, p o r k bur noi1.c travail pcrconncl. Notla y di-crlvons Ics rihultats c o i ~ r l tcrrne pour I t . groupe clr New York el celui d e Slt~iskil LC "carly-pntency-rate'' I New York \e Irlonrre ;I 93 5 X , celui d c Sl~r~skrl ,'I 100% Le l ~ t l c n c y vale eii pour New York ,ipr&.r 5 ans J c X9'T cl pour S l ~ r ~ i k r l nprtr; 3 a n \ eoic.ore t o n / a ) t ~ r ~ d e 100%
Notis iuvonb 0bserv6 2 (;(>I\ A N C W York 'Iliac comil--~l~caznon portant S L U ~ U I I C rrSrlirlotilii7~~hc \1.11tc d uns i h r a i ~ a t ~ o ~ ? de valve (une r.C~si[en.vent~trn ftnl el'rcclukc
;r\i.ec iucck4 chef cch dcux p a r ~ c ~ u t ~ ) .
P,rrnai Ic\ p;112e111.; d c Sluisk~l ducune re-occl~ustnn, su ~ l c utic forrnatlon c4e v , ~ l v t ~ l e dc I'intjn~a ne Fut cnnstntee, r n ~ i d ~ s qu'ul surw~nr~ Line l'ols ume t ~ k t i ~ o r r - Y1;~glc dnna I'arz&se l~onzc~ lalkralc ~lnaclucl cxternc 'ipres usage dw la glu~llotl~lc de LcVeen Certe h k m o r ~ I1;tgle nkcesslta, u n r r'kunlc'r\~cn ~1013.
Aucunc a ~ l ~ ~ p l l c a t r o n tardivc tze ftlt col~\iatt!c A Sl~~i\'kil, land15 q u ' i New York 8 rk-uccluuon\ burvinrcn1 elidknns Its I b 5 an3
D ~ I I ~ la zro~sl2rne Partic de cette drssertaslon nlous tlkcrivonb 113 dc.\oblrti-r,il~on ds I'rlr~Cre aorta-~liay ue (fernorale) par vale rCtn-open~onirrle
A l'alde d'un reportage pi-roropraphuquc nous S L I I V O I ~ S I'optirat~on pas ,l pa$, Nous dttcr~vons lcb rbsultats dcs operatians yue IIIOU\ .IVOIIC ~>r;l~lqt~ees Nen York el a Slulbkll.
I 1.a dksobl~terar~c~~a p,tr la cju~llot~nc de LeVeen t i l C r v t e u n e place d c choix p;lrmI lei; teehniq~ics op6ra~o11.c~ de la clvlrusgle anrkr~elle r&cons~rucr~ve.
2. L',ipyrocllc ~klrop>r~tonrdle de la Okslon aorta-ll~aque esc s ~ ~ p k r ~ e u r e h I'dtp- proche i~ .inrp6ri1onCale.
3. La dksoblltkratiola scloll LeVeen. par la vuie r&~roptrutont~zle, pour auzarlll q u k l l e salrffasw a u k conditrons decr~tes din~ls cette tl~kse. est 111-1 ccsmplCnrrc~iz bicnwcn~~ 211, chlrurg~e ii;lsoula~~e
4. Les ltsrorzs ~or~o-ili;rca-fCra~~~r~~le~ pcuvent etre Cgalrrnerr~ op6r6~5 ~ C ~ O I Z
tech~iic]ue\ qthe nous avons dCcnlss dans u n 1?8p1fal pCrnph&r.lqire. } X t t l f I I I U ~
b ~ e n &q~~lpC.
