RU2168949C2 - Surgical method for treating aorta coarctation of postductal type in adult patients - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves mobilizing aorta after performing thoracotomy and selection of the aorta. The proximal region of anastomosis is formed in performing lateral squeezing of aorta with natural collateral vessels being retained. When building the anastomosis, subclavicular artery is also involved. The anastomosis is created as prosthesis-end-to-aorta-and-subclavicular-artery-side type anastomosis. Application of this approach being technically impossible, the aorta is transected and the anastomosis is created as aorta-end-to-prosthesis-end- to-subclavicular-artery-side type anastomosis after performing lateral squeezing of the subclavicular artery. Anastomosis lines are treated with medical sulfacrylate glue. EFFECT: prevented cuts through aorta walls and hemorrhages from anastomosis. 4 dwg

Description

 The invention relates to medicine, namely to surgery of the great vessels, and is intended to perform the correction of congenital malformation - coarctation of the aorta.

 It is known that the surgical treatment of coarctation at the age of 20-40 years (the 5th critical period according to Yu. A. Berezov and A.V. Pokrovsky, 1965) is associated with technical difficulties that arise with age-related changes in blood vessels: expansion of the post-stenotic area, thinning of the wall aorta, expansion of intercostal arteries and thinning of their walls. A serious and frequent complication of aortic coarctation is bacterial endocarditis, which is observed in 6-22% of patients (I.A. Medvedev, 1970; Campbell, 1970).

 To eliminate coarctation in these patients, a method of prosthetics of the coartition site with a synthetic vascular prosthesis is used, in which the prosthetic-vessel sutures are superimposed on the thinned, easily penetrated aortic wall and 1-2 pairs of intercostal arteries are ligated, which in itself presents certain difficulties (A. A. Shalimov, 1974).

 The prototype of the invention is the method described by De Beckey et al. in which the site of coarctation of the aorta is bypassed by a corrugated vascular prosthesis. “The corresponding lateral clamps are applied proximal and distal coarctation to a suitable segment of the aorta. A linear incision of the aortic wall can be made in the switched off segment of the aorta while maintaining relatively unchanged blood flow over the aorta. A suitable prosthesis can be sewn obliquely to the side of the aorta. Proximal anastomosis” end to side "is performed first, and after it the distal end-to-side anastomosis is lower than coarctation (M. E. De Beckey, D. A. Cooley, E. S. Crawford, D. S. Morris. Surgery of the aorta and large peripheral arteries. Medgiz , 1960, p. 33).

 The disadvantage of this method is that the walls of the altered aorta easily erupt, causing significant bleeding from the anastomoses. When mobilizing the aorta, 1-2 pairs of intercostal dilated, thinned fragile arteries must be ligated and stitched, which causes ischemia of the spinal cord, often irreversible at this age. During the operation, the aorta, the left subclavian artery, the internal thoracic artery, the vertebral artery (with subclavian subclavian), which are natural collaterals providing the arterial pool below coarctation, are pinched.

 The aim of the invention is the prevention of complications in the process of clamping the aorta and the application of anastomoses.

 The task is achieved in that the proximal anastomosis is superimposed on the aorta under the mouth of the subclavian artery, capturing the subclavian artery, the walls of which are stronger than the altered aorta. The distal anastomosis is superimposed on the type of "end to side" below the confluence of the first 2 pairs of intercostal arteries, on the lateral extraction, without turning off the collateral circulation from the aorta and intercostal arteries. In this case, the lines of anastomoses are treated with Sulfacrylate medical glue, which has antibacterial and sealing properties, which reduces blood loss through anastomoses, serves to prevent septic rejection of the prosthesis and increases the strength of the entire structure (Plechev V.V., 1992).

 In FIG. 1 shows the imposition of lateral extraction on the aorta and subclavian artery with complete preservation of the initial blood flow.

 In FIG. 2 shows the application of a clamp to the aorta and subclavian artery with partial preservation of the initial blood flow.

 Figure 3 shows a method of forming a proximal anastomosis of the type "end of the prosthesis into the side of the aorta and subclavian artery" with partially preserved blood flow.

 Figure 4 shows a method of forming a proximal anastomosis of the type "end of the aorta to the end of the prosthesis and into the side of the subclavian artery" with a fully clamped aorta and partially preserved blood flow through the subclavian artery. Anastomosis is initially formed with the subclavian artery.

 The method is as follows. After thoracotomy and isolation of the aorta 1 with the coarctation site 2, the latter is mobilized and a lateral extraction 3 is applied to its proximal part in the first embodiment (Figure 2), so that half of the clamp falls on the mouth of the subclavian artery 4, and the second half on the aorta. A proximal anastomosis 5 is formed with a prosthesis of the type “end of the prosthesis into the aortic side” with a continuous suture, it is important that the suture starts from the wall of the subclavian artery 4. When the formation of the anastomosis is completed, the sulfacrylate medical glue is applied to the anastomosis line. Retreating 5 mm from the line of the anastomosis, a clamp is applied to the prosthesis and the lateral extraction is removed. In the second embodiment, the vascular clamp is applied in such a way that the aorta is compressed completely, and the left subclavian artery is squeezed 1/3 of the lumen. The formation of a proximal anastomosis is similar to the first option.

 On the intact section of the descending aorta, below 1-2 pairs of intercostal arteries, a lateral extraction is superimposed on the front-left lateral wall of the aorta (Fig. 3). A distal anastomosis is formed according to the type of “end of prosthesis to the side of the aorta” with a continuous suture. The anastomosis line is treated with Sulfacrylate medical glue (Fig. 4), the side extraction is removed. No bleeding is noted.

 Example 1. Patient I. East. diseases N 6386. During the operation to eliminate aortic coarctation in a patient I. 40 years old, a 3 cm long coarctation was detected. The narrowed aortic section begins directly below the mouth of the left subclavian artery, the post-stenotic section of the aorta is expanded to 5 cm, from it depart: a functioning open arterial duct 8 mm wide, 2 pairs of intercostal arteries expanded to 5-7 mm. The walls of the open arterial duct and intercostal arteries are thinned, fragile. The left inner thoracic artery and the left subclavian artery are expanded to 1 cm.

 The visceral pleura is dissected, the aorta is isolated and its proximal portion from the left carotid to coarctation is mobilized. The abbot artery is crossed between two clamps, its ends are stitched and bandaged. A functioning open ductus arteriosus between two vascular prostheses is crossed, stitched, and twice ligated. The duct stumps are sealed with sulfacrylate medical glue. No bleeding from duct stumps was noted.

 A lateral extraction is applied to the wall of the aorta and subclavian artery so that the blood flow is preserved along the subclavian artery and aorta. An anastomosis with a lavsan prosthesis N 22 of the type "end of the prosthesis to the side of the aorta and subclavian artery", previously impregnated with autoblood, was applied with a 4/0 thread, a continuous suture. Moreover, the suture began with the subclavian artery. After the suture was completed, the anastomosis line was sealed with Sulfacrylate medical glue and a clamp was applied to the prosthesis, 5 mm from the anastomosis. No bleeding from the sutures was noted. On the intact section of the aorta, below the confluence of the 2nd pair of intercostal arteries, lateral extraction is applied so that blood flow is preserved along the aorta and intercostal arteries. A distal anastomosis of the type “end of the prosthesis to the side of the aorta” was applied with a 4/0 thread with a continuous suture. The anastomosis line is also sealed with Sulfacrylate medical glue. A retrograde shunt blood flow is included.

 No bleeding from the anastomosis was noted. In the 7th intercostal space, drainage with a rubber tube was left. The wound is sutured.

 Drainage removed on the 2nd day. Skin sutures were removed on the 7th day. Healing by first intention. Neurological disorders in the postoperative period were not observed.

 Inspected after a year. Hypertension is kept within 150/90 mm Hg. (versus 220/100 mmHg) Works. Physical activity tolerates satisfactorily.

 Example 2. Patient G. 33 years. East Disease N 3414. Operated on coarctation of the aortic postductal type. During the operation, coarctation of the aorta over 4 cm, a functioning open ductus arteriosus, was revealed. A complete block of the descending aorta was noted. The visceral pleura is dissected, the aortic region from the left carotid artery to coarctation is mobilized. A functioning PDA is crossed between two clamps, stitched and double-tied. The duct stumps are sealed with sulfacrylate medical glue. There was no bleeding from the duct stumps.

 A vascular clamp is applied to the aorta and the mouth of the subclavian artery, so that the aorta is fully compressed, and the left subclavian artery is squeezed 1/2 of the gap. Partial blood flow in the left subclavian artery is preserved.

 A 4/0 thread with a continuous suture with lavsan prosthesis No. 20 after preliminary soaking with autologous blood, an anastomosis of the type “end of the prosthesis to the end of the aorta and the side of the subclavian artery” was applied, the suture of the anastomosis began from the unchanged wall of the subclavian artery. The anastomosis is sealed with Sulfacrylate medical glue. A clamp was applied to the prosthesis, 5 mm from the anastomosis, and the vascular clamp was removed from the aorta and subclavian artery. No bleeding was noted.

 Below the first two pairs of intercostal arteries, lateral extraction is superimposed. The blood flow through the aorta and intercostal arteries is preserved.

 A distal anastomosis with a prosthesis of the type "end of the prosthesis to the side of the aorta", which is also sealed with glue "Sulfacrylate", was placed on the intact site with a 4/0 thread with a continuous suture. A retrograde and then antegrade blood flow through the prosthesis is included. No bleeding was noted.

 In the 7th intercostal space, drainage with a rubber tube was left, which was removed on the 2nd day. Sutures were removed on the 7th day. Healing by first intention. In the postoperative period, neurological disorders were not observed.

 Inspected after a year. There are no episodes of hypertension. Works. Physical activity tolerates satisfactorily.

 Using the proposed method, 22 adult patients with pre-ductal aortic coarctation with initial high hypertension were operated on. None of the patients in the postoperative period showed neurological complications, suppuration of wounds.

Claims (1)

 A method for surgical treatment of post-ductal aortic coarctation in adult patients, including prosthetics of the aortic region with a synthetic vascular prosthesis with proximal and distal anastomoses, while forming a distal anastomosis with lateral aortic squeezing with preservation of blood flow through natural collaterals of the type "end of prosthesis to the side of the aorta", characterized in that the proximal anastomosis is formed during lateral squeezing of the aorta while maintaining blood flow through the natural collaterals and impose it on the aorta at the mouth of the subclavian artery, capturing the subclavian artery, of the type “end of the prosthesis into the side of the aorta and subclavian artery”, and if it is impossible to technically perform this technique, the proximal anastomosis is applied after crossing the aorta and lateral extraction of the left subclavian artery of the type “end of the aorta to the end of the prosthesis and into the side of the subclavian artery, "and the lines of the anastomoses are subsequently sealed with Sulfacrylate medical glue.

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