RU2471430C1 - Method of treating juxtarenal aneurysm of abdominal aorta by method of aorto-femoral bifurcation bypass grafting - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular, to cardio-vascular surgery. Access to aorta is made from left-sided thoracophrenopararectal retroperitoneal cut with isolation of suprarenal part of abdominal aorta and common iliac arteries. Clamping of aorta is performed parietally on left lateral wall in suprarenal part with preservation of blood flow. Longitudinal aortotomy is performed in the area of parietally clamped aorta. Proximal anastomosis is applied above origin of renal arteries. Retroperitoneal cellular tissue is tunnelled to femoral artery. Bifurcation jaws of prosthesis are passes in formed tunnels. Distal anastomoses of bifurcation jaws of prosthesis with femoral arteries in the area of common femoral artery bifurcation by "end-to-side" type are performed. Main blood flow in prosthesis jaws after formation of residual antegrade blood flow is directed through aneurysm which is formed after ligation and suturing common iliac arteries in terminal part if abdominal aorta.

EFFECT: method makes it possible to reduce postoperative complications, which is achieved due to preservation of blood flow in the process of operation.

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Description

Technical field

The invention relates to medicine, in particular to cardiovascular surgery, and can be used to treat juvenile aneurysm (JuA) of the abdominal aorta.

State of the art

JuA of the abdominal aorta poses a threat to human life due to the high risk of rupture.

Jura (juxta - from Latin juxta - located nearby) is characterized by the fact that the upper border of the aneurysmal sac (AM) begins at the level of the mouths of the renal arteries or between them. It is characterized by parietal thrombosis, and with a high degree of development (due to the patient’s late appointment to the doctor), the formation of AM, which does not have a “neck” below the renal arteries, is associated with a risk of impaired blood supply to the kidneys and other internal organs.

Known surgical method for the treatment of JuA of the abdominal aorta by aortic-femoral bifurcation bypass, described in the source Belov Yu.V. A guide to vascular surgery with an atlas of surgical techniques. - M .: DeNovo, 2000 .-- p.194-198.

The known method includes a complete median laparotomy with subsequent access to the aorta under the diaphragm through the cavity of the lesser omentum for subsequent compression of the aorta together with the celiac trunk, mobilization of the anterior wall of the aorta with the ileal arteries, dissection of the Treitz ligament after pulling the initial section of the jejunum to the right, crossing and ligation of the inferior mesenteric vein, complete mobilization from the surrounding tissues of the left renal vein by ligation and intersection of vessels flowing into it, mobilization of ne of the unilateral lateral aorta and the initial sections of the renal arteries, sequential compression of the aorta and celiac trunk below the diaphragm, iliac, lower mesenteric and renal arteries, opening the aneurysm to the lumen, performing thrombectomy and stitching of the lumbar arteries, continuing to cut the aneurysm to its upper edge at the mouth level , the formation of the posterior wall of the proximal anastomosis 5-10 mm below the mouth of the renal arteries, starting from the left renal artery, with stitches inside the aorta and prosthesis, clamping on 1-2 cm below the anastomosis and removal of the clamp from the aorta, control of hemostasis along the suture line, flashing the mouths of the common iliac arteries from the side of the aorta and bandaging them outside, tunneling the retroperitoneal tissue to the femoral artery, passing bifurcation branches of the prosthesis into the tunnels formed, performing distal bifurcation anastomoses branches of the prosthesis with femoral arteries in the area of bifurcation of the common femoral artery of the type "end to side" and the direction of the main blood flow through the bifurcation prosthesis.

In the known method, the aorta and the celiac trunk are completely squeezed out or squeezed below the diaphragm, iliac, superior mesenteric and renal arteries with a temporary cessation of blood flow in them, as a result of which the main blood flow in the abdominal organs, pelvic organs, lower limbs, kidneys stops and increases the risk of their ischemic damage, especially in patients with long-existing chronic renal failure, occlusive lesions of the arteries of the lower extremities, diffuse-distal type of lesion a Theurillat tibia, as well as in patients with acquired valvular defects, whose long cross-clamping the aorta, followed by a sharp start of peripheral blood flow in the early postoperative period may lead to cardiac decompensation.

The known method is characterized by large blood loss, it is complex and time consuming.

The above method of treating JuA of the abdominal aorta, described by Yu.V. Belov in the above Guide on p.194-198, is the closest to the claimed method in terms of the set of essential features and is selected as the closest analogue (prototype).

Disclosure of invention

The problem to which the invention is directed is the development of a simplified but effective method for treating JuA of the abdominal aorta with the method of aorto-femoral bifurcation bypass surgery that preserves blood flow through the aorta and visceral arteries during surgery and minimally exposes the organs of the abdominal cavity and retroperitoneal space to intraoperative ischemia.

The result that can be obtained by using the invention is to simplify the treatment method and reduce its time while improving the quality of treatment of patients with severe concomitant pathology by reducing postoperative mortality.

To solve the problem and achieve the claimed result in a method of treating an abdominal aorta with aortic-femoral bifurcation bypass surgery, including access to the abdominal aorta below the diaphragm, squeezing the aorta above the renal arteries, performing a proximal anastomosis with the main prosthesis jaw, pressing the iliac arteries, squeezing the iliac arteries, retroperitoneal tissue to the femoral artery, conducting bifurcation branches of the prosthesis into tunnels formed, performing distal anastomoses bifurcation branches of the prosthesis with femoral arteries in the area of end-to-side bifurcation of the common femoral artery and the direction of the main blood flow through the prosthesis according to the invention, aortic femoral bypass surgery is performed contactless with respect to the aneurysm with the possibility of complete thrombosis to the level of the renal arteries, while access to the aorta is performed from the left thoracophrenopararectal retroperitoneal incision with the release of the suprarenal part of the abdominal aorta and common iliac arteries and with a revision of of the mesenteric artery, the aorta is squeezed out parietally along the left side wall in the suprarenal part with preservation of blood flow through the abdominal aorta, visceral arteries and arteries of the lower extremities, before applying the proximal anastomosis, a longitudinal aortotomy is performed in the area of the parietal squeezed aorta, form a “window the imposition of the proximal anastomosis with the main jaw of the prosthesis, prepare the main jaw of the prosthesis by stretching and compressing it along the lateral surfaces and performing obliquely on it about a “cobra” -type cut with reaching the correspondence of the length of the cut-off part of the prosthesis jaw to the diameter of the “window” formed in the aorta, the proximal anastomosis is placed above the renal artery discharge, the common iliac arteries are squeezed out with their simultaneous dressing and the formation of a “blind” aneurysmal sac to overlap the main blood flow through the aneurysm and the creation of residual antegrade blood flow through it to complete thrombosis of the specified “blind” aneurysmal sac.

Distinctive features of the prototype of the features of the claimed method are the following:

- the implementation of aortic-femoral bypass surgery is non-contact with respect to the aneurysm with the possibility of its complete thrombosis to the level of the renal arteries;

- access to the aorta from the left thoracophrenopararectal retroperitoneal incision with the release of the suprarenal part of the abdominal aorta and common iliac arteries and with revision of the inferior mesenteric artery;

- performing an aortic squeeze parietal along the left side wall in the suprarenal part with preservation of blood flow through the abdominal aorta, visceral arteries and arteries of the lower extremities;

- performing a longitudinal aortotomy in the area of a parietal squeezed aorta before applying a proximal anastomosis,

- the formation of a “window” in the aorta for applying a proximal anastomosis with the main branch of the prosthesis;

- preparation of the main jaw of the prosthesis by stretching and compressing it along the lateral surfaces and making an oblique cut on it like a “cobra”, achieving the correspondence of the length of the cut part of the jaw of the prosthesis to the diameter of the “window” formed in the aorta;

- the imposition of a proximal anastomosis above the discharge of the renal arteries;

- squeezing the common iliac arteries with their simultaneous ligation and the formation of a “blind” aneurysmal sac to block the main blood flow through the aneurysm and create residual antegrade blood flow through it until the thrombosis of the specified “blind” aneurysmal sac is complete.

These distinctive features, individually and collectively, are aimed at achieving the stated result and are significant. In the prior art, the combination of known and distinctive features presented in the claims is not known.

The proposed method for the treatment of JuA with aortic-femoral bifurcation bypass grafting is illustrated by figures, in which Fig. 1 shows the general scheme of the operation, Fig. 2 shows a longitudinal section with the results of surgical treatment. Aorto-femoral bypass surgery is performed under general anesthesia using a vascular prosthesis made of polytetrafluoroethylene.

The method is as follows:

a longitudinal section along the projection lines of the arteries in the region of the Scarpovsky triangle isolate and revise first the right and then the left femoral arteries. Access to the abdominal aorta 1 from the left retroperitoneal thoracophrenopararectal incision with the release of the suprarenal part of the abdominal aorta 1, common iliac arteries 2 and the inferior mesenteric artery (Fig. 1). To do this, a skin incision is performed along the 7-8 intercostal space, starting from the posterior axillary line. At the costal arch, the skin incision is rotated and led down in accordance with the projection of the lateral edge of the rectus abdominis muscle and complete the incision, not reaching 5 cm to the inguinal fold. Intercostal muscles cross along the upper edge of the underlying rib. Open the left pleural cavity. Then cross the cartilage of the costal arch and aponeurosis along the lateral edge of the vagina of the rectus abdominis muscle. Enter the preperitoneal space, then the peritoneum is widely separated with a tuffer along with the kidney and paranephric tissue from the muscles, starting from the pelvic region and ending with the diaphragm. A dull and sharp path separates the peritoneum from the diaphragm. Electric knife cross the diaphragm towards the aorta. Wide hooks divert the peritoneum and left kidney medially. Then, the left leg of the diaphragm and paraaortic tissue directly above the aorta 1 are cut with an electric knife. Aorta 1 is extracted along its left side wall 3 above and below the renal arteries 4, the aorta 1 is freed from surrounding tissues in the places of subsequent manipulation with it, and the common iliac arteries are revised 2. After that, using the holders, squeeze the aorta 1 above the discharge of the renal arteries 4, and squeeze the clip 5 parietally by about 2/3 of its clearance along the left side wall 3 in the suprarenal department ie with preservation of the blood flow, visceral arteries and the arteries of the lower extremities. A longitudinal aortotomy of the required size is performed in the area of the parietal squeezed aorta 1 and the formation of a “window” for applying the proximal anastomosis of the aorta 1 with the main jaw 6 of the prosthesis, for which thrombotic masses (if any) are carefully removed from the aortic lumen 1 with forceps and the inside of the squeezed aorta 1 washed with a stream of physiological solution. Prepare the main jaw 6 of the prosthesis for applying the proximal anastomosis: it is stretched, squeezed along the lateral surfaces and cut at an angle of 30-45 ° depending on the anatomical ratio of the stitched aorta and the prosthesis, forming a “cobra” -type slice, matching the length of the cut part of the jaw 6 prostheses the length of the formed “window” in the aortic wall 1. Perform a proximal anastomosis with the prepared main jaw 6 of the prosthesis, which is applied above the discharge of the renal arteries 4, using continuous bvivnoy seam, which is custom made prosthesis from the heel upwards forming the first left, then right sides of the anastomosis, after which the filaments bind among themselves. After removing the clamp 5 from the aorta 1, the prosthesis is squeezed 5 mm below the anastomosis and washed to evacuate possible thrombotic masses and material emboli. Next, perform an audit of the inferior mesenteric artery. If it is occluded, which happens with thrombosed aneurysms of the abdominal aorta, then intestinal blood supply is compensated collaterally through the system of the superior mesenteric artery (Reolan's arch). If the diameter of the artery is sufficient (more than 3 mm), there is patency and weak antegrade blood flow from it, then reimplantation of the inferior mesenteric artery into the prosthesis is performed, while the artery is crossed, the proximal end is ligated with stitching, and then a hole with a diameter of up to 5 is cut with a scalpel mm, where the inferior mesenteric artery is then sutured with a continuous twisting stitch. Then the iliac arteries 2 are squeezed out with their simultaneous dressing in place 7 to block the main blood flow through the aneurysm 8. Next, the retroperitoneal fiber is tunneled to the femoral arteries using the index fingers of both hands of the surgeon and bifurcation branches of the prosthesis 9 are made into the tunnels formed. Perform distal anastomoses of the bifurcation branches of the 9th prosthesis with the femoral arteries in the bifurcation region of the 10th common femoral artery 11 of the end-to-side type. The clamp is removed from the prosthesis and the main blood flow is directed along the prosthesis.

As a result of the operation, the initial AM, open from both the proximal and distal ends, turns into a “blind” AM 12, open only from the proximal end 13, complete thrombosis up to level 14 below the renal artery 4 discharge, which provides residual, antegrade blood flow (Fig. 2). Upon reaching the indicated level of thrombosis, this blood flow by aneurysm ceases.

The claimed method for the treatment of juvenile aneurysm by aortic-femoral bypass, compared with the prototype, has the following advantages:

- non-contact of aortic-femoral bypass surgery with respect to aneurysm, which means that aneurysm is not secreted and its lumen is not opened, and this reduces the time of surgery and significantly reduces the risk of intraoperative blood loss;

- access to the aorta from the left thoracophrenopararectal retroperitoneal incision, which provides a broad approach to the entire abdominal aorta and its visceral branches, does not require mobilization of the duodenum, allows a wide choice of the level of aortic clamp application, shortens the time of surgical intervention;

- minimal trauma to the surrounding tissues, reducing the risk of damage to internal organs during the allocation of the abdominal aorta and reducing the risk of bleeding;

- a decrease in possible intraoperative blood loss due to the exclusion of clamps and intersections of visceral branches;

- the exception of prolonged preparation of the aorta, excretion of AM and renal arteries;

- performing an aortic squeeze parietally along the left side wall in the suprarenal part with preserving blood flow through the abdominal aorta and visceral arteries during all stages of the operation, which prevents the development of ischemia of the abdominal cavity, kidneys and lower extremities;

- performing longitudinal aortotomy in the area of the parietal squeezed aorta while maintaining the main blood flow through the aorta;

- direction of the main blood flow through the prosthesis with the formation of residual antegrade blood flow through the aneurysm after ligation and flashing of the common iliac arteries in the terminal section of the abdominal aorta, which creates artificial conditions for the formation of blind AM and thrombosis of the aneurysm cavity immediately distal to the renal arteries leaving this zone off main blood flow.

The formation of “blind” AM occurs with a gradual decrease in the rate of residual blood flow in the cavity of the aneurysm, which contributes to its thrombosis, while thrombosis at the level of the renal arteries does not occur due to the fact that the velocity of the main blood flow in the aorta at this level remains higher, and the residual blood flow upon reaching the indicated level of thrombosis stops.

Example: Patient G., 66 years old, was admitted on 10.26.2010 to the Department of Vascular Surgery of the University Clinical Hospital No. 1 (BCH No. 1) of the First Moscow State Medical University named after I.M. Sechenov. Preliminary diagnosis: Atherosclerosis with damage to the aorta and arteries of the lower extremities. Infrarenal abdominal aortic aneurysm. Ischemic heart disease. Postinfarction cardiosclerosis. Arterial hypertension, II stage, risk 3. Primary uncomplicated varicose veins of the superficial veins on the left leg with valvular insufficiency of the superficial and communicative veins on the lower leg. Chronic venous insufficiency of the left leg II tbsp. Peptic ulcer of the stomach and duodenum. Upon receipt, the general condition is relatively satisfactory.

Given the high risk of complications, it was planned to perform an operation on 10.11.2010, including aneurysm resection and aortic-femoral bifurcation prosthetics. However, after performing a left thoracophrenopararectal incision and revision of the abdominal aorta, it was found that an aneurysm 12 × 8 × 7 cm in size immediately spreads from the level of renal artery discharge to the level of aortic bifurcation, spreading to the common iliac arteries, and there is no pulsation of the inferior mesenteric artery. As a result, an intraoperative diagnosis was made: Juxtarenal abdominal aortic aneurysm. Given the impossibility of adequately compressing the aorta below the level of renal artery passage, it was decided to perform aortic-femoral bypass surgery with a proximal anastomosis with suprarenal abdominal aorta end-to-side and ligation of the iliac arteries. The suprararenal aorta and common iliac arteries were isolated. The aorta is taken onto the holders and squeezed out parietally. Performed a longitudinal aortotomy. Performed aortic-femoral bypass surgery with bifurcation prosthesis GORTEX No. 20 according to the described method. Distal anastomoses are formed with common femoral arteries in the area of end-to-side bifurcation. A proximal anastomosis is placed on the left side wall of the aorta below the diaphragm. In this case, the common iliac arteries are bandaged. Before the application of distal anastomoses, an open endarterectomy was performed from the left superficial femoral artery. Antegrade blood flow from the femoral arteries is satisfactory. Upon removal of the clamps, the pulsation of the femoral arteries and graft is distinct. A thorough hemostasis was performed. Installed drainage in the left pleural cavity. Layer wound closure was performed. Six months later, the patient was examined using multispiral computed tomography with contrast, the results of which confirmed that the shunt is functioning and there is no renal artery thrombosis.

The first experience of using the claimed method for treating juvenile aneurysm with a non-contact method demonstrates its promise, as it allows to simplify and accelerate surgery, significantly reduce blood loss, eliminates ischemia of the abdominal organs, less traumatic and more effective from the point of view of postoperative rehabilitation.

Applicability

The proposed method of treatment is suitable for use in all clinics.

Claims (1)

A method for the treatment of juvenile abdominal aortic aneurysm by aortic-femoral bifurcation bypass surgery, including access to the abdominal aorta, squeezing the aorta above the renal artery, performing a proximal anastomosis with the main branch of the prosthesis, squeezing the iliac arteries, tunneling the retroperitoneal tissue, retroperitoneal tunneling bifurcation branches of the prosthesis, performing distal anastomoses of bifurcation branches of the prosthesis with femoral arteries in the area of bifurcation of the common femoral artery of the end-to-side type and the direction of the main blood flow through the prosthesis, characterized in that the aortic-femoral bypass surgery is performed contactless with respect to the aneurysm with the possibility of complete thrombosis to the level of the renal arteries, while access to the aorta is performed from the left thoracophrenopararectal retroperitoneal incision with the release of the suprarenal part of the abdominal aorta and common iliac arteries and with the revision of the inferior mesenteric artery, the aorta is pressed parietally the left side wall in the suprarenal section with preservation of blood flow through the abdominal aorta, visceral arteries and arteries of the lower extremities, before applying the proximal anastomosis, longitudinal aortotomy is performed in the area of the parietal squeezed aorta, a “window” is formed in the aorta for applying the proximal anastomosis with the main prosthesis jaw, preparation of the main jaw of the prosthesis by stretching and compressing it along the lateral surfaces and performing an oblique cut on it like a “cobra” on it to achieve compliance with the length of the cut part of the jaw of the prosthesis with the diameter of the “window” formed in the aorta, the proximal anastomosis is applied above the renal artery discharge, the common iliac arteries are squeezed out with their simultaneous ligation and the formation of a “blind” aneurysmal sac to block the main blood flow through the aneurysm and create residual antegrade blood flow through it complete thrombosis of the specified "blind" aneurysmal sac.

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