RU2193355C1 - Method for treating inconsistent venous valves by applying microsurgical reconstruction techniques - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making longitudinal venotomy in the area of valve sinus between commissures. Free cusp edge lengths are measured. Half-difference between the free cusp edge length and a half of vein circumference is marked on the free cusp edge. The free cusp edge is captured at a distance equal to redundant free edge length drawn from commissure by piercing inside from outside with atraumatic needle. Threads are brought outside from vein lumen by making pierce outside from inside. The second neocommissure is built on the other side. Intraparietal circular purse- string sutures are stitched in adventitia without constricting vein lumen in supra- and subvalvular segments. Threads are left in building the neocommissures used for making longitudinal intraparietal sutures in the adventitious proximal direction from the neocommissures fixing them to the superior circular purse-string suture. EFFECT: prevented recidivation. 4 dwg

Description

 The invention relates to medicine, namely to microvascular surgery.

 A known method of microsurgical reconstruction of a failed venous valve (R. Kistner "Surgical archive" volume 110, p. 1336-1342 Surgical restoration of a failed valve of the femoral vein. November 1975).

 According to Kistner’s surgery, a cut along the upper third of the thigh isolates the femoral veins and finds a valve, usually located at the mouth of the femoral vein. After clamping, the blood is displaced proximally. With the resumption of retrograde current, a failed valve passes blood into the subvalvular segment of the vein. When restoring an insolvent valve, a clamp is applied and the vein is cut longitudinally 3 cm below the valve in the proximal direction through the commissure of the cusps and the incision is continued further by 3 cm, warning of the possibility of damage to the cusps when cut in the commissure region. Overstretched lowered valve flaps are found to allow backward flow of blood. Restoration is done by sewing on an excess leaflet leaf to the vein wall at the attachment point to the vein wall with 4-6 interrupted sutures, for which an atraumatic needle with a thread 6/0 - 7/0 is inserted inside the vein through a puncture from the inside, and the sashes are captured on 2 mm from the edge of the mount, then the needle with the thread through the puncture from the inside out. Knots are tied on the outer wall of the vein. Similarly, the valves are reduced on the part of the dissected commissure. The question of the degree of sash reduction is considered debatable. Phlebotomy is sutured with interrupted sutures, they are warned about the possibility of deformation of the valves. After closure of phlebotomy, the competence of the valve is checked. If the valve is defective, the operation is repeated or the vein is ligated.

 The disadvantage of this method is the unreasonably large incision of the vein.

 Dissection of a vein through a commissure is dangerous by accidental but probable damage to the leaflets. A significant vein incision lengthens the operation, conducting it through the lower hemisphere of the valve leads to its deformation when the incision is sutured. The technique does not provide for the restoration of disturbed relationships of valve structures in the dilated vein. No measures are taken against its further dilution.

 As the closest analogue, the method of microsurgical reconstruction of insolvent vein valves, including opening the vein and pulling the valve flaps, is adopted. The length of the semicircle of the vein is measured, it is cut longitudinally in the region of the upper hemisphere, proximal to the level of commissures from the proximal to the distal between the commissures, the length of the free edge of the valves is determined, after which half the difference in the measured lengths is laid on the free edge of the valves, the points of which are subsequently fixed above the level of the commissures, thus forming neo-commissions. Additionally, in the region of the upper and lower levels of attachment of the leaflets, intra-wall circular purse-string sutures in adventitia are imposed without narrowing the lumen of the vein. (AC 1674813, class IPC A 61 B 17/00, 1991).

 However, the known method has a significant drawback. It does not eliminate the possibility of further dilatation of the venous wall of the valve as a result of the varicose process, resulting in a distal disposition of neocomissures with lowering of the valves, leading to relapse of valve insolvency. The possibility of eruption of sutures of the venous wall in the area of neocomissures is also not ruled out, which leads to relapse of valve insolvency.

 The objective of the invention is to provide a method of microsurgical reconstruction of insolvent vein valves, which prevents the occurrence of relapse due to the long-term relationship of valve structures.

 The essence of the invention lies in the fact that in the method of microsurgical reconstruction of failed valves of the veins, which consists in the fact that after measuring the length of the semicircle of the vein, it is cut longitudinally in the region of the upper hemisphere proximal to the level of commissures from proximal to distal between commissures, the length of the free edge of the valves is determined, and then half the difference in measured lengths is laid on the free edge of the valves, the points of which are subsequently fixed above the level of commissures, thus forming neocomissures, veins they are sutured continuously with a nodular suture, then the intra-wall circular purse-string sutures in adventitia are applied without narrowing the lumen of the vein, the circular purse-string sutures are placed in the supravalvular and subvalvular segments of the vein, and when neocomissures are formed, the threads are applied by which the longitudinal intra-parietal sutures are inserted in the non-proventural direction in the adventurea and fix them to a circular purse string suture without deformation of the venous wall.

 Using the invention allows to obtain the following technical result. Strengthening the venous-valve segment of the upper hemisphere of the valve, additional fixation of neocomissures allows preserving the relationship of valve structures without disturbing the mechanism of their functioning, and preventing the distal positioning of the valves, which prevents relapse of the valve.

 The method allows to obtain a pronounced clinical effect, which consists in the persistent prevention of venous reflux through valve flaps, normalization of hemodynamics, namely, a decrease in venous hypertension. Functional blood circulation in the lower extremity is restored in patients, trophic disorders regress.

 Duration of hospital stay is reduced, and full rehabilitation and restoration of disability occur much faster.

 The resulting effect is persistent. Using the method allows you to return the ability to work and improve the quality of life of patients, as well as expand the contingent of patients previously considered unpromising in the outcome of surgical treatment.

 EFFECT: persistent prevention of insolvency relapse is achieved by ensuring the most physiological functioning of the valve, the absence of venous reflux, and persistent preservation of the contact area of valve flaps due to additional fixation of neocomissures.

 The method is as follows (Fig.1 - 4). The soft tissues of the upper third of the thigh are cut laterally from the Ken line to a length of 8-10 cm, and the common femoral, femoral and deep femoral veins are distinguished. Typically, a valve is found at the mouth of the femoral vein. Distal valve impose a vascular occluser. Blood is squeezed in the proximal direction. In retrograde blood flow, an insolvent valve passes it into the subvalvular segment. Next, an occlusor is placed proximal to the valve, and if necessary, into a deep vein. A vein in the region of the valvular sinus is cut longitudinally strictly in the middle between the commissures for 8 - 10 mm, and two thirds of the incision is performed proximal to the level of commissures. The length of the free edge of the cusps is measured, half the difference between the length of the free edge of the cusp and the length of the semicircle of the vein is laid on it at each commissure. Next, create neocommissions. Atraumatic needle with non-absorbable suture 8/0 - 9/0 is inserted into the lumen of the vein through a puncture from the outside inward above the level of the commissures, the free edge of the cusps is picked up at a distance of the excess free edge length delayed from the commissure, and the thread is taken out of the vein from the inside through the puncture from the outside (Fig. 1) and knot knot on the outside of the vein wall, the thread is not cut. Similarly, create a second neo-commission on the other hand. The vein incision is sutured continuously with a nodal suture (Figure 2). Remove the proximal occlusor. Increase pressure in the supravalvular segment of the vein. By the retrograde filling of the valve sinus with blood and its absence in the subvalvular segment, the restored valve closure function is judged. Remove the rest of the occlusers. Non-absorbable atraumatic thread 7/0 - 8/0 impose the upper and lower intraparietal circular purse-string sutures in adventitia of the vein in the supravalvular and subvalvular segments without narrowing the lumen of the vein (Figure 3). The next step is the fixation of neocomissures to the circular purse string suture. The threads left after the formation of the neocomissure impose longitudinal intra-wall sutures in adventitia from the neocomissure in the proximal direction with fixation to the upper circular purse string suture without deformation of the venous wall (Figure 4). This is to prevent recurrence of valve failure. The operation is completed by layering the wound.

 Example. Patient O. 32 years old, an employee, was admitted to the hospital on 02/04/1996 with complaints of swelling of the left lower leg and ankle joint, appearing in the morning, not completely disappearing after rest, orthostatic cruralgia, the presence of varicose veins, trophic disorders of the left skin lower legs. Sick since 19 years, the disease gradually progressed, a sharp deterioration after the first pregnancy. On examination: on the anterior - medial surface of the left thigh and left lower leg in the pool of the great saphenous vein, varicose nodes, palpation painful, soft - elastic consistency. Swelling of the ankle and lower third of the leg, with pressure, dimples remain. In the lower third of the tibia along the medial surface, the induction zone is up to 6x5 cm. In retrograde phlebography, the failure of the femoral vein valves was revealed (discharge of contrast medium to the popliteal vein). With ultrasound dopplerography - the failure of the femoral vein valve. Given the failure of the valve apparatus of the femoral vein, the patient was offered surgical treatment - microsurgical reconstruction of the femoral vein valve with combined phlebectomy in the saphenous vein system. 02/07/1996, an operation was performed under epidural anesthesia - microsurgical reconstruction of the femoral vein valve with the prevention of relapse, combined phlebectomy in the saphenous vein of the left lower limb. A section of 10 cm in length on the front surface of the left thigh, starting under the inguinal fold and extending laterally down the Ken line, highlights the total (OBV), femoral (BV) and deep (HBV) femoral veins. Insolvent valve revealed at the mouth of the BV. After testing the valve and confirming its failure on OBV, BV, GBV superimposed occluders. Venotomy between commissures strictly in the middle for 8 mm. During the audit, the valve is two-fold, the free edges of the valves sag to the level of the bottom of the valve. The length of the semicircle of the vein and the excess amount of the free edge of the valves were measured. Neocomissures were created by suturing half the excess length of the free edge of the cusps with suturing the vein wall proximal to the commissure level by half the excess length of the free edge of the cusps with thread 8/0 on both sides. The vein incision is sutured with 8/0 thread. After removing the occluders from the OBV and the HBV, when testing the valve, there is no blood flow to the subvalvular segment - the valve is sound, the occlusor is removed from the BV. Thread 7/0 imposes intra-wall circular purse string sutures in adventitia of the vein in the supravalvular and subvalvular segments. The threads left after the formation of the neocomissure imposed longitudinal intra-wall sutures in the adventitia of the vein from the neocomissure in the proximal direction with fixation to the upper circular purse string suture. Hemostasis control is dry. Layer wound closure. A combined phlebectomy was performed in the saphenous vein system. Stitches for wounds. Elastic bandage.

 The patient was examined three months after the operation. Marked disappearance of edema, orthostatic cruralgia, regression of trophic disorders of the skin of the leg.

 The patient was examined after 5 years - there is no relapse of varicose veins, no edema and orthostatic cruralgia. Trophic disorders of the skin of the leg no. With UZDG, the reconstructed BV valve is consistent.

Claims (1)

 A method for microsurgical reconstruction of insolvent vein valves, including longitudinal section of the vein in the region of the valve sinus in the middle between the commissures, measuring the length of the free edge of the cusps, laying off half the difference between the length of the free edge of the cusp and the length of the semicircle of the vein, picking up the free edge of the cusp at a deferred distance from the commissure of the length of the excess of the free edge by puncture from the outside inward with an atraumatic needle, removing the filament from the lumen of the vein through the lumen from the inside out, tying a knot on the outer side of the vein wall, similarly creating a second neocomissure on the other hand, applying intra-wall circular purse-string purse-string sutures in adventitia without narrowing the lumen of the vein, characterized in that the purse-string sutures are laid in the supravalvular and subvalvular segments of the vein, and are left during neocomissure formation filaments with which longitudinal longitudinal wall sutures are applied in adventitia in the proximal direction from neocomissures with fixation to the upper circular purse string suture without venous deformity th wall.

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