RU2160057C2 - Method for forming main vein valve - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves creating a valve by screwing-in vein wall. External membrane is removed which size is 1.3 times as large as the vein diameter. Sutures are put-in on the vein axis. Needle is introduced at the level of dissected external membrane edges. The needle goes out 0.3 cm proximal and distal with respect to the point of needle introduction with two lateral sutures previously put-in and muscular membranes captured. The needle goes out in proximal position through all venous membranes with tightening the sutures next to it. EFFECT: eliminated valvular insufficiency. 6 dwg

Description

 The invention relates to medicine, namely to vascular surgery, and is used for chronic venous insufficiency / CVI / lower limbs.

 Known methods of forming a valve of the main veins / B. Eiseman, W. Malette // Surg. Cynec. Obstet., 1953. - Vol. 4. - N 4. - P. 731-734; E.Yu. Tyunder, E.I. Sepp // Actual issues of surgery. Tartu, 1974. - S. 133-134; P. P. Kovalenko, I. I. Kotelnitsky - "Method for the formation of the valve of the main veins", copyright certificate N 1355252. Bull. open invented 1987, N 44 /.

 The listed methods for forming the valve of the main veins are based on screwing the vein wall into its lumen using sutures at the level of the intersection of the vein and immersing its distal end into the proximal.

 Treatment without creating an artificial valve in CVI is ineffective. A study of the pathogenesis of the disease made it possible to determine that as a result of post-thrombotic vascular recanalization, the venous valves are completely destroyed, which leads to absolute valve failure. Therefore, a crucial factor in the pathogenetically substantiated treatment of CVI is the reconstruction of the valves of the main veins.

 However, the above methods of forming a valve from a vein wall have several disadvantages: after thrombosis, thrombophlebitis, and periphlebitis, the vein wall changes so much that it is very difficult to screw it into the lumen of the vein in the proximal direction. The formed valve consists of 2 layers of the vein wall, so the newly formed valve cannot function as a valve and subsequently takes its previous position or even narrows the lumen of the vein with subsequent venous hypertension in the distal section / B. Eiseman et al., 1953 /. Further, in the anatomical plan, as such, the valve is not formed, and when the veins cross in the cross section, both the nerve and vascular formations of the veins themselves intersect, which violates the innervation and vascularization; from here, and in a functional respect the valve does not work / E.U. Tunder et al., 1974 /.

 As a prototype, we took a method of forming a valve of the main vein by invagination of the distal into the proximal, when only the internal one is screwed after excision of the outer and middle membranes / V.M. Leshchenko, A.A. Alekseenko // Actual issues of surgical treatment of vascular disease. - M., 1977 .-- S. 162-163 /.

 However, after a thrombotic process, the wall of the vein is so thickened and sclerotic that it is technically impossible to separate all its membranes. Therefore, when forming the valve in the described prototype method, insufficient fixation is often possible, which leads to disinvagination and fibrosis of the created valve.

 In addition, the removal of the middle / muscle / sheath and with it the neurovascular formations of the vein wall affects the functional ability of the formed valve.

In this situation, it is rational to use the criteria on the basis of which a preliminary assessment of the proposed methods of venous valve repair should be carried out:
1. It is impractical to provide the prevention of retrograde venous blood flow by forming structures that violate the natural antegrade blood flow.

 2. Methods should be designed for significant initial pathological changes in the walls of the main veins.

 3. Newly formed valve structures should not create a threat of thrombosis of the main veins.

 4. Created valve structures should have obvious valve functions that do not disappear as a result of subsequent organization and deformation in the long term / VB Gervaziev, 1991 /.

 Based on these criteria, we proposed the following method of venous valve formation. It is based on the principle: the manufacture of "non-spill ink" with the formation of the shape of a double-leaf valve.

 The purpose of the invention is to increase the clinical effect by eliminating valve failure in patients with chronic venous insufficiency of the lower extremities.

 The goal is realized by the prototype method as follows: after excision of the outer and middle membranes of the vein, the distal vein is invaginated into the proximal with subsequent suturing of the dissected membranes in the transverse direction, and according to the proposed method, a valve is formed by screwing the vein wall into its lumen using sutures applied along the vein axis with preliminary excision of the outer membrane 1.3 times as wide as the diameter of the vein, and the application of two lateral sutures with an atraumatic needle with capture of the muscle membranes a valve created so that the needle puncture was made through the vein proximal to the shell.

 The method is illustrated in the drawing, where 1 / hydraulic preparation of the outer sheath of a vein: a / outer shell, b / middle shell, in / inner shell; 2 / application of two lateral sutures with an atraumatic needle; 3 / suturing along the axis of the vein; 4 / general view after applying all the seams; 5 / final view; 6 / transverse view.

 The method is as follows: after processing the surgical field, under general anesthesia with a sharp and blunt way, we isolate a pathologically altered vein from paravasal structures, where absolute valve insufficiency up to 8 cm long is determined. The vein is taken on holders from both ends. Then, under the hydraulic preparation, the outer membrane is excised with a width 1.3 times the diameter of the vein itself / drawing, 1 /. After that, the valve is formed by screwing the vein wall into its lumen using sutures applied along the axis of the vein so that the needle is injected at the level of the edges of the excised outer sheath, and the puncture is 0.3 cm proximal and distal to the injection and the two lateral sutures are preliminarily applied atraumatic needle with the capture of muscle membranes so that the needle is injected proximal through all the vein sheaths / drawing, 2, 3 /. At the same time, the newly created valve is based on the principle: the manufacture of an "ink-spill" with the creation of the shape of two flaps. The stage when the seams are superimposed, but the threads in the drawing are not tightened, 4. And the final stage is the drawing, 5, 6.

 The proposed method differs from the prototype in that, firstly, the external membrane of the vein is excised with preservation of the middle / muscle / and inner membrane; secondly, in the lumen of the vein, the valve is central to the blood flow, both of its surfaces are covered with intima and endothelium; thirdly, to prevent the valve from dropping in the distal direction with a strong retrograde push of the blood and creating a valve shape in the form of two wings, side seams are additionally applied with an atraumatic needle; fourthly, the newly created valve works in one direction from the periphery to the center, which is based on the principle: the manufacture of "non-spill inkwells"; fifthly, after the tension of the joints imposed along the axis of the vein, a sleeve is formed distal to the created valve; sixthly, we preserve the innervation and vascularization of the created valve due to the middle shell; seventh, the newly created valve structure is closer to the anatomical form and to some extent performs valve functions.

 A similar method was applied to 23 patients with chronic venous insufficiency of the lower extremities. In total, 23 operations of the formation of the venous valve by type were performed: the manufacture of an “ink-spill” with the creation of the shape of two wings. In 12 patients, valve plastic surgery was performed as an independent operation, and in 11 as an element of complex intervention; in combination with perforant ligation, and in some patients with saphenous vein phlebectomy and Linton surgery. Good near and long-term results were obtained in 15 patients, satisfactory in 7, and one showed functional failure of the created valve, which is associated with a technical error at the beginning of the development of the method.

 More favorable and stable outcomes were observed in patients undergoing complex intervention. We did not observe a single case of femoral vein thrombosis in the plastic zone either in the near or in the distant period. Patients have been observed since 1993 in the General Surgery Clinic of the Dagmedakademiya and the Regional Cardiovascular Center of Rostov-on-Don.

 Indications for use of the proposed method of valve formation is absolute valve failure in patients with CVI of the lower extremities, i.e. 3rd and 4th degree of valve insufficiency.

 Thus, the proposed method of forming a valve according to the principle: the manufacture of an "ink-spill" with the creation of two flaps allows you to create vascular structures that maintain viability and to some extent perform valve functions. Its use in an isolated version or in combination with other surgical techniques significantly improves the orthostatic venous hemodynamics of the lower extremities in patients with CVI due to damage to the valve apparatus of the main veins.

 Positive effect.

 In contrast to generally accepted known methods, the proposed method allows to increase the clinical effect by 1.5 - 2 times, reduce the number of complications and shorten the treatment time.

Examples of specific performance of the method:
Example 1. Patient Gebekova P.Kh., 33 years old, I.b. N 1754/623, was admitted to the clinic on September 28, 93 with a diagnosis of post-thrombophlebitic disease of the left lower limb, an edematous-varicose form complicated by a trophic ulcer of the lower third of the leg. Condition after phlebectomy of the saphenous veins of the lower extremities.

 Sick since 1987 after artificial abortion, suffered acute ileo-femoral venous thrombosis on the left. Since 1989, against the background of gradually developing pigmentation and induction, a trophic ulcer has opened in the lower third of the lower leg, which has periodically closed. On admission, the left lower limb is larger in volume / swells / than the right, 10.5 cm / lower leg /, 8.3 cm / hip /. On the lower third of the left leg, hyperpigmentation, maceration of the skin, on the inner surface of a trophic ulcer 1.5 x 2.0 cm in size. A pronounced picture of pseudovaricosis of saphenous veins.

 Functional tests were not performed due to the presence of edema and severe pain.

 Phlebotonometry of saphenous veins allowed to note - 256 mm of water. Art. in a prone position.

 Dopplerography is determined by the insolvency of the femoral vein valves on the left, and dopplerometrically - arterial blood flow disturbances due to edema of the tissues of the left lower limb.

 Distal venography: recanalization of deep veins, valves do not differentiate. Perforating discharge into the saphenous vein system of the lower leg. Contrast the main veins of the thigh failed. Retrograde femoral venography: recanalization of the femoral vein with complete valvular insufficiency.

 The patient underwent a 2-week course of preoperative preparation by training venous circulation of the lower limb according to the treatment method stated in the application N 93-015922 dated 03/26/93. The condition improved, limb edema decreased, trophic ulcer of the lower leg almost at the stage of granulation and epithelization, size 0, 5 x 0.6 cm. 10/14/93 - the operation of the formation of a venous valve in the femoral vein on the left by the principle of "ink-spill" with the creation of the shape of a bicuspid valve in combination with subfascial clipping of perforating veins from small access by the method developed in the clinic. Elastic compression Walking is allowed for 5 days. Wound healing by primary intention. The ulcer was almost completely epithelized. 10.28.93 was discharged home in satisfactory condition. Inspected after 3 years; no ulcer recurrence, slight swelling / after a long walk /, pigmentation almost completely disappeared.

 Example 2. Patient Huseynova P.G., 37 years old. I.b. N 1773/645, was admitted to the hospital on 1.10.93 with a diagnosis of post-thrombophlebitic disease of the left lower extremity, edematous form, stage 3, complicated by a trophic ulcer of the lower third of the left leg.

 The disease is 15 years old. She suffered acute thrombosis of the main veins after childbirth. Conservative treatment gave a temporary effect. On examination, the left lower limb is larger in volume / swells / than the right, 9.6 cm / lower leg /, 6.5 cm / thigh /. Varicose veins are slightly expressed. In the region of the lower third of the left tibia, on the medial surface there is a trophic ulcer measuring 2.0 x 0.8 x 0.5 cm, with dense edges. Around the ulcer, the skin is inductively altered, eczematized.

 Dopplerographic determination of complete valvular insufficiency of the femoral vein.

 Distal venography: recanalization of deep veins, valvular apparatus does not differentiate, perforating discharge at the lower leg level. Retrograde femoral venography: recanalization of the femoral vein with absolute valvular insufficiency.

 Phlebotonometry of the saphenous veins made it possible to note 275 mm of water. Art. in a prone position.

 The patient underwent a 2-week course of preoperative preparation by training venous circulation of the lower extremities according to the method of treatment stated in the application N 93-015922 of 03/26/93. After preparation, the edema of the lower extremity decreased by almost 2 times, the trophic ulcer in the granulation and epithelization stage, the sizes were 0.6 x 0.5 cm. 01/15/93, the operation of forming a venous valve according to the principle: the manufacture of "ink-spill" with the creation of a double-leaf valve. Elastic compression Walking is allowed from 4 days. From day 5 I received a training course for venous circulation, but with a gradual increase in the load. The wound healed by primary intention. The trophic ulcer was epithelized on day 10. 01/28/93 was discharged home in satisfactory condition. Examined after 3.5 years. There is no relapse of the ulcer. Pigmentation of the lower leg decreased significantly. By the end of the working day, there is a slight swelling in the ankle of the left lower leg.

Claims (1)

 A method of forming a valve of the main veins in case of chronic venous insufficiency of the lower extremities, which consists in creating a valve by screwing the vein wall, characterized in that the outer sheath is excised with a width 1.3 times the diameter of the vein itself, then sutures are applied along the vein axis so that the needle was made at the level of the edges of the excised outer sheath, and the puncture was 0.3 cm proximal and distal to the injection with the preliminary application of two lateral sutures with the capture of muscle membranes and the needle was proximal to the black without all vein sheaths, followed by tightening all sutures.