RU2161013C1 - Surgical method for treating deep vein dysfunction - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making invalid vein segment by-pass by applying two indirect by-passes. The by-passes are placed on diametrically opposed sides of the vein segment to be by-passed. By-passe cross-section centers are shifted by a value equal to by-pass diameter in positioning along the length of the segment to be by- passed. One by-pass is arranged in the deep vein bed. The second one is positioned in subcutaneous fat tunnel formed. The segment under by-pass is ligated on both sides at a distance of 10 mm from the nearest edges of the internal anastomoses. EFFECT: reduced risk of stenosing and extravasal compression. 6 dwg

Description

 The invention relates to the field of vascular surgery, namely to plastic and reconstructive operations on the main veins (with thrombosis, insolvency of vascular valves and vascular injury).

 A known method of surgical treatment of deep vein dysfunction with a free graft - shunt. As a shunt, a large saphenous vein with a full valve apparatus of the contralateral limb is used. A proximal shunt anastomosis is formed with a stump of a large saphenous vein of a diseased limb, the trunk of which is not removed, but is used as a bed for a shunt. A distal anastomosis is formed with a large communicative vein in the upper third of the leg. Crossed at this level, the large saphenous vein of the diseased limb is fixed with sutures on top of the anastomosis to the fascia of the lower leg. All tributaries of the dilated large saphenous vein used as a bed for a shunt are bandaged from small incisions [1].

 The disadvantage of this method is that it does not provide normal blood outflow due to the fact that the diameter of the shunt is less than the diameter of the main vein, as a result of which pronounced narrowing of the main trunk, stenosis, is formed in the places where the anastomoses are performed. In addition, the shunt is placed in a limited space - the bed of a deep vein, and it can be squeezed by neighboring tissues, i.e. extravasal compression of the vessel occurs. All of the above leads to thrombosis and, as a consequence, obstruction of the shunt.

 The task of the invention is to improve venous outflow due to the elimination of reflux, restore patency (integrity) of the vessel, reduce the risk of thrombosis and increase the reliability of the operation.

 The objective of the method for the surgical treatment of deep vein dysfunction, including shunting of a leg of an incompetent vein and placing a shunt in a deep vein bed, is achieved by placing anastomoses of two bypass shunts on the diametrically opposite sides of the shunted vein with an offset along its length relative to the centers of the shunt sections by an amount equal to the diameter of the shunt, then the shunted area is ligated on both sides at a distance of 5-10 mm from the near edges of the internal anastomoses, while the second shunt is placed they are burnt in a previously formed subcutaneous tissue tunnel.

 The proposed method and features that distinguish it from those known in the medical and patent literature are not found, which allows us to conclude that its criterion of "novelty" is met.

 The essence of the invention lies in the fact that anastomoses of two bypass shunts are placed on the diametrically opposite sides of the shunted section of the main vein with a shift along its length relative to the centers of the shunt sections by an amount equal to the diameter of the shunt, then the shunted section is ligated on both sides at a distance of 5-10 mm from the nearest edges of the internal anastomoses, with one shunt placed in the bed of a deep vein, and the second in a previously formed tunnel of subcutaneous tissue.

 The application of two shunts increases the outflow of blood, because the diameter of one shunt is less than the diameter of the main vein, and two shunts provide an adequate outflow of blood.

 Anastomoses of bypass shunts are placed on diametrically opposite sides of the shunted section of the main vein with a shift along its length relative to the centers of the sections of the shunts by an amount equal to the diameter of the shunt, so that there is no stenosis of the main trunk at the sites of anastomoses.

 The shunted area is ligated to turn it off from the blood circulation and, thus, the full effect of the application of shunts is achieved.

 In addition, ligation of the shunted area on both sides at a distance of 5-10 mm prevents deformation of the vessel in the areas of anastomosis, thereby reducing the risk of thrombosis.

 A distance of 5 mm ensures the safety of the vessel, i.e. uniform surface tension in the areas where anastomoses are performed - no “corrugation” assemblies are formed. If the distance is less than 5 mm, then corrugation assemblies are formed in the areas of the anastomoses.

 If the distance is more than 10 mm, then there is a high risk of blood clots in a blind pocket.

 A distance of 5-10 mm from the near edges of the internal anastomoses was worked out during experiments on 35 dogs.

 Placing one shunt in the bed of the main vein, and the second in the subcutaneous tissue tunnel provides reliable blood flow through the shunts, as in case of compression of one of the shunts and violation of its function, the second shunt continues to function.

 Thus, the totality of all the distinguishing features allows you to achieve the task and get a positive result.

 The implementation of the method is illustrated by drawings.

 FIG. 1 is a general diagram of an operation.

 FIG. 2 - ultrasound sonogram before surgery.

 FIG. 3 - ultrasound duplex sonogram on the 14th day after the operation.

 FIG. 4 - ultrasound duplex sonogram 8 months after surgery.

 The method is as follows. Fence of two shunts of the required length is performed according to the generally accepted technique. As shunts, any large superficial veins with intact valves are used, the removal of which does not violate the venous outflow in the corresponding region and whose diameter is sufficient to perform shunts. Check the viability of the valve apparatus by pumping saline with heparin in the retrograde direction, and the patency of the shunts in the antegrade. Then, in the Skarp triangle in the projection of the neurovascular bundle, the femoral vein is isolated and mobilized for 10-12 cm. The next stage is the isolation and mobilization of the femoral vein at the border of the middle and lower third of the femur for 10-12 cm.

 Then, a tunnel is formed in the subcutaneous tissue, in which one of the shunts is placed. After that, distal and proximal anastomoses are performed with the selected sections of the femoral vein according to the generally accepted technique. The second shunt is placed in a bed of a deep vein. In this case, anastomoses are placed on the diametrically opposite sides of the shunted femoral vein with a shift along its length relative to the centers of the shunt sections by an amount equal to the diameter of the shunt. Then the shunted area is ligated on both sides at a distance of 5-10 mm from the proximal edges of the internal anastomoses.

 Then, surgical wounds are sutured in layers, sutured to the skin and covered with aseptic dressings.

 The proposed method is implemented in the presented clinical example.

 Patient Sh., 47 years old, and / b N 415707.

 The patient lies on his back, skin incisions are performed on the medial surfaces of both thighs in the projection of the large saphenous vein. Trunks of both large saphenous veins are isolated and mobilized for 18-20 cm. The indicated segments of large saphenous veins are sampled according to the generally accepted technique. Check the viability of the valve apparatus of the shunts by pumping saline with heparin in the retrograde direction, and the patency of the shunts in the antegrade. Then, in the Scarp triangle in the projection of the neurovascular bundle of the diseased limb, the femoral vein is isolated and mobilized for 10-12 cm. The next stage is the isolation and mobilization of the femoral vein at the border of the middle and lower third of the femur for 10-12 cm.

 Then, a tunnel is formed in the subcutaneous tissue, in which one of the shunts is placed. After that, distal and proximal anastomoses are performed with the selected sections of the femoral vein according to the generally accepted technique. The second shunt is placed in a bed of a deep vein. In this case, anastomoses are placed on diametrically opposite sides of the shunted section of the femoral vein with a shift along its length relative to the centers of the sections of the shunts by an amount equal to the diameter of the shunt. Then the shunted area is ligated on both sides at a distance of 7 mm from the proximal edges of the internal anastomoses.

 Then, thorough hemostasis is performed and the surgical wounds are sutured in layers, sutured to the skin and covered with aseptic dressings. After that, elastic bandaging of the leg of the operated limb is performed in order to strengthen the venous current through the deep veins and performed shunts.

 After the operation, the patient noted a significant improvement: edema decreased, bursting pains and muscle cramps in the leg of the operated limb disappeared.

 Before surgery, a diagnostic ultrasound Doppler study was performed - pronounced venous reflux (more than 5 s) in the femoral vein was observed with a Valsalva test (Fig. 2).

 On the 14th day after the operation, a control ultrasound duplex scan was performed on an ACUSON 128 X / P10 device - the shunts are completely passable, when Valsalva is sampled by a shunt located in the femoral vein bed, venous reflux is not visualized (Fig. 3a), by shunt, located in the subcutaneous tissue, a short reflux is visualized (no more than 2 s), which corresponds to the time of physiological closure of the valves (Fig. 3b), in other words, the valve apparatus of the shunts is completely consistent and, reflux in the femoral vein operated There is no liver.

 Eight months after the operation, a control ultrasound duplex scan was also performed - the shunts are passable, the Valsalva test is negative on both shunts (Figs. 4a, 4b).

The proposed method allows you to:
1. Significantly improve venous blood flow and functional results.

 2. To reduce the risk of stenosis and extravasal compression and, as a consequence, thrombosis.

 3. Improve the reliability of the operation.

 The method was tested at the RSCH RAMS, gave positive results and will be widely used in vascular surgery.

 Sourse of information.

 1. AN Vedensky Plastic and reconstructive operations on the main veins. - Leningrad: Medicine, 1979, pp. 155-156.

Claims (1)

 A method of surgical treatment of deep vein dysfunction, including shunting of a leg of an incompetent vein and placing a shunt in a deep vein bed, characterized in that anastomoses of two bypass shunts are placed on the diametrically opposite sides of the shunted vein section with a shift along its length relative to the centers of the shunt sections by an amount equal to the diameter the shunt, then the shunted area is ligated on both sides at a distance of 5-10 mm from the proximal edges of the internal anastomoses, while the second shunt is placed in the previously formed subcutaneous tissue tunnel.

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