RU2210988C2 - Method for surgical treatment of failed valvular venous apparatus - Google Patents

Abstract

FIELD: medicine, vascular surgery. SUBSTANCE: one should longitudinally dissect the vein between folds' commissures. At detecting the difference in commissures; levels against each other being above 4 mm one should additionally perform their leveling by creating new points for commissures' fixation to venous fold by applying excess of free edge of valvular folds. For this purpose, at the side of lower commissure one should carry out valvulopexy by developing neocommissure at the level of higher one, or neocommissure is created by descending the above-lying commissure up to the level of below-lying one, or one should simultaneously lift lower and put down higher commissure by creating two neocomissures at one and the same level. The present innovation enables to remove anomalies in valvular folds' construction. EFFECT: higher efficiency of surgical therapy. 9 dwg, 3 ex, 1 tbl

Description

 The invention relates to medicine, in particular to vascular surgery, and can be used for the surgical treatment of insolvent valve apparatus of the veins.

 Known methods for surgical treatment of failed valves [see Kistner R. Surgical repair of an incompetent femoral vein valve. The surgical archive T. 110, 1975, from 1336-1342]. This known method includes longitudinal section of a vein through the points of commissures and reduction of the cusps by suturing them with a surgical suture.

 The known method has the following disadvantages: the need for a large length of the vein incision with the intersection of the lower fibrous ring, which is carried out through the point of the upper commissure, which reduces its strength, as well as the strength of the fibrous ring, the application of 2-3 sutures to reduce the leaflet area, empirically - a decrease in the area of the cusps reduces the contact area of the cusps, and therefore reduces the valve closure function, a large percentage of failures, forcing the author to ligate the femoral vein.

 There is also known a method of surgical treatment of insolvent vein valves [see author St. USSR 1674813 dated May 6, 1991], in accordance with which they tighten the free edges of the valve flaps, bringing their length to the length of the semicircle of the vein at the level of commissures.

 The specified method, adopted by us as a prototype, largely eliminates the disadvantages of the above known method and is effective in the treatment of stretched flaccid flaps that do not provide a tight closure in the closed state.

 The known method described above has the disadvantage that it does not provide for various abnormal variants of valve leaflet development, such as, for example, with a different level of commissures and a different degree of plasticity of the valve leaflets.

 The objective of the present invention is to remedy this drawback.

 The problem is solved in the present method of surgical treatment of a failed valve apparatus of the veins by reconstruction, including providing access to the opening of the veins, for which a vein is cut longitudinally in the region of the upper hemisphere of the valve, the status of the valve apparatus is determined, including the difference in the level of commissures relative to each other and when a difference greater than 4 mm is detected, they are judged about their disharmony (dysplasia, atypicality) and in this case, the commissure points are aligned to an almost uniform level ny, for which they surgically create, using the excess of the free edge of the cusps, new points of commissures, while lowering the existing attachment points of commissures lower along the vein or lifting them depending on the ductility of the valve cusps, which is determined intraoperatively by the degree of their extensibility, and then corrected the length of the free edges of the valve cusps, pulling their edges in a known manner, bringing their length to the semicircle of the vein at the level of new commissures.

The proposed method will be further described based on the drawings, where
figure 1 shows a sectional view of an insolvent valve of normal structure with weakened sashes;
Fig. 2 shows a sectional view of an insolvent valve of an atypical structure with different levels of commissures;
in FIG. 3 shows a sectional view of an insolvent valve with a different level of commissures and plastic valves in the process of its surgical reconstruction;
in FIG. 4 shows a sectional view of an insolvent valve with a different level of commissures and plastic valves in the process of continuing its surgical reconstruction;
in FIG. 5 shows a sectional view of an insolvent valve with various levels of commissures and moderate hypoplasia of the valves in the process of its surgical reconstruction;
in FIG. Figure 6 shows a sectional view of an insolvent valve with different levels of commissures with significant hypoplasia of the valves in the process of its surgical reconstruction.

The figures depicted in the drawings have the following position names:
1 - a trunk of a vein;
2 - vein wall;
3 - upper fibrous ring;
4 - lower fibrous ring;
5 - valve area;
6 - valve sinus;
7 - line of fastening of the valve leaf;
8 - consolidated edge of the valve leaf;
9 - cut line of a vein;
10 - bottom of the valve;
11 - left commissure;
11 '- left neocomissure;
12 - right commissure;
12 '- right neo-commission;
h is the difference in the level of commissures relative to the conditions of the normal transverse vein section line.

 The method is carried out in the following way (see figure 1).

 After processing the surgical field, a longitudinal incision is made of the femoral tissues 12-15 cm long along the front surface of the femur under the pupartic ligament in the projection of the vascular bundle. In the usual way, the femoral vein 1 is isolated at the location of the valve 5, which manifests itself as a spheroid extension of this segment of vein 1, as well as above and below this segment. A milking test is carried out to determine the closure function of valve 5: distal to the location of valve 5 on the femoral vein 1, a vascular clamp is applied and blood is displaced with the finger proximally, after the finger pressure ceases, the blood rushes retrograde, and with good closure function of valve 5 of the sash 8, it closes without passing blood into the subvalvular space, below the bottom of the valve 10, the vein 1 remains empty, and when the valve 5 is inactive, it is filled with blood. After verifying the incompetence of valve 5 of the femoral vein 1, after applying the vascular clamp proximally under an operating microscope (ORTON), vein 1 is cut longitudinally by section 9 between commissures 11, 12 above and below their level for 10-15 mm and the valve is inspected, for which they are measured the difference in the levels of the diametrical arrangement of the commissures 11, 12 relative to each other and when revealing the difference in levels exceeding 4 mm, they are judged by their disharmony and ductility of the valves 8, which is judged by the degree of their ability to stretch. Valve 5 with a different level of commissures 11, 12 and normoplastic sashes 8 on the side of lower commissure 12 produce valvuloplexy with the creation of neocomissure 12 'at the level of higher commissure 11. For this, an atraumatic thread is introduced through the puncture of the vein wall 1 at the point of the future neocomissure 12' with the needle 8.0, and using the excess length of the valves 8, both valves 8 are captured by the needle at a distance necessary to bring them to the level of neocomissure 12 ', retreating 1 mm from the outer edge. An atraumatic thread is passed through the flaps 8, and a needle with a thread is punctured outside the wall of the vein, near the injection site. Outside veins 1, 4-5 knots are tied. The free edges of both valves 8 are pulled to the site of nodes inside the vein 1, the venotomy opening is sutured with a continuous-nodal suture. After this, the proximal vascular clamp is removed, and the blood rushes in the retrograde direction, but, reaching the bottom of the valve 10 with the closed valves 8, does not penetrate into the subvalvular space, the valve 5 is consistent.

 In the case of hypoplasticity of the valves 8 of the valve 5 (Fig. 5), two neocomissures 11 ', 12' are created. On the side of the lower commissure 12, the neocomissure 12 'is created higher than the previous one, and on the side of the higher commissure 11 it is created lower, and the sum of the distances by which commissures 11, 12 fall and rise is equal to the length of the difference of commissures h, the length of the free edge of the wings 8 is reduced to the length of the semicircle of vein 1 at the level of neocomissures 11 ', 12'.

 When aplasticity (Fig.6) of the valves 8 creates a neocomissure 11 'on the side of the overlying commissure 11, but at the level of the underlying commissure 12. Layer-by-layer suturing of the surgical wound.

 If it is revealed that valve 5 (see Fig. 1) has the same level of commissures 11,12 and its failure is caused by sagging of the changed free edges of the valves, then the reconstruction is carried out in accordance with the well-known author. St. USSR 1674813 of May 8, 1991. The known method does not provide guidance for cases where the failure of valve 5 is due to other reasons, the elimination of which is not considered in the present invention.

 The described technique is illustrated by the following examples.

Example 1
Patient Karpenko T.V., 35, medical history 2658, was admitted to the microsurgery department for varicose veins of the left lower extremity 111A with complaints of dilated saphenous veins on the left lower extremity, swelling of it after 2 hours of standing, fast fatigue and bursting pain in the calf muscles with prolonged stay on the legs. Ultrasound dopplerography of the veins of the lower extremities and retrograde femoral phlebography were performed in the patient's department, which revealed the failure of the proximal femoral vein valve.

 Operation: microsurgical reconstruction of the failed atypical valve of the femoral vein. Under epidural anesthesia after processing the surgical field, an incision in the upper third of the left thigh is 12 cm long. The skin, subcutaneous tissue, and thigh fascia are dissected. A vascular bundle and a femoral vein have been isolated. In the femoral vein, a valve is determined in the form of a spheroidal expansion of the vein, through the wall of which commissures are visible. Distal to the valve, a vascular clamp is applied to the vein and the blood is displaced in the proximal direction, when the pressure ceases with a finger, the blood rushes retrograde and freely penetrates the subvalvular space (finger test), which confirms the absence of the valve closure function. Superimposed vascular clamps on the femoral vein proximal to the valve and on the deep femoral vein. Under an operating microscope with a magnification of 5, the vein is dissected from the level above the visible commissure by 2 mm downwards, over a length of 15 mm. The lumen of the vein is washed with saline NCL with heparin.

 An intravenous valve audit was performed, it was revealed that there is a bicuspid valve with a commissure level difference of 12 mm, the valves are normoplastic. Atraumatic thread 8.0 through a puncture of the vein wall from the outside to the inside, at a point on the side of the underlying commissure, but at the level of the superior commissure is inserted into the lumen of the vein, the free edges of both valves are captured by a needle with an atraumatic thread, 1 mm from the free edge and at a distance from the underlying commissure sufficient to raise the leaflets to the neocomissure 12 mm higher than the previous one and bring the length of the free edge of the leaflets to the length of the semicircle of the vein. Atraumatic thread with a needle brought out of the vein wall through a puncture near the injection point. By applying 5 knots outside the wall of the vein, the flaps are pulled up to the level of neocomissure, bringing the length of their free edge to the length of the semicircle of the vein. The venotomy opening is sutured with a continuous-nodal suture. The proximal clamp is removed, the blood rushes retrograde, but does not penetrate into the subvalvular space below the closed valve flaps, the valve is consistent. Layer wound closure.

 A superficial venectomy was performed according to Beccoccus, Coquette. Stitches for wounds. Aseptic dressing. Elastic bandage of a limb.

 In the postoperative period, the patient was prescribed heparin 2.5 thousand units. 4 times a day subcutaneously, antibiotic therapy. Sutures were removed on day 10, healing by first intention. There are no complaints of the patient about dilated veins, swelling of the limbs and pain in the calf muscles. With control ultrasound dopplerography, the valve is consistent.

Example 2
Patient Kuznetsova N.A., 26, medical history 2639, was admitted to the microsurgery department for varicose veins of the right lower limb 111A with complaints of dilated saphenous veins on the right lower limb, her edema, rapid fatigue and bursting pain in the calf muscles with prolonged stay on your feet. After ultrasound dopplerography of the veins of the lower extremities and retrograde femoral phlebography revealed the failure of the proximal valve of the femoral vein.

 Operation: microsurgical reconstruction of the failed atypical valve of the femoral vein. Under epidural anesthesia after processing the surgical field, an incision in the upper third of the left thigh is 12 cm long. The skin, subcutaneous tissue, and thigh fascia are dissected. A vascular bundle and a femoral vein have been isolated. In the femoral vein, a valve is determined in the form of a spheroidal expansion of the vein, through the wall of which commissures are visible. Distal to the valve, a vascular clamp is applied to the vein and the blood is displaced in the proximal direction, when the pressure ceases with a finger, the blood rushes retrograde and freely penetrates the subvalvular space (finger test), confirming the absence of the valve closure function. Superimposed vascular clamps on the femoral vein proximal to the valve and on the deep femoral vein. Under an operating microscope, with a magnification of 5, the vein is dissected from the level above the visible commissure by 2 mm downward for 15 mm. The lumen of the vein is washed with saline NCL with heparin.

 An intravenous audit of the valve was performed, it was revealed that there is a bicuspid valve with a commissure level difference of 12 mm, the valves are hypoplastic. With atraumatic thread 8.0, two neocomissures were created at the same level, the overlying commissure was lowered by 7 mm, the underlying commissure was raised by 5 mm, bringing the length of their free edge to the length of the semicircle of the vein. The venotomy opening is sutured with a continuous-nodal suture. The proximal clamp is removed, the blood rushes retrograde, but does not penetrate into the subvalvular space below the closed valve flaps, the valve is connected. Layer wound closure.

 A superficial venectomy was performed according to Beccoccus, Coquette. Stitches for wounds. Aseptic dressing. Elastic bandage of a limb.

 In the postoperative period, the patient was prescribed heparin 2.5 thousand units. 4 times a day subcutaneously, antibiotic therapy. Sutures were removed on day 10, healing by first intention. There were no complaints of the patient about dilated veins, swelling of the extremities and pain in the calf muscles, the skin in the area of hyperpigmentation brightened. With control ultrasound dopplerography, the valve is consistent.

Example 3
Patient Yatsenko V.P., 41, medical history 287, was admitted to the microsurgery department for varicose veins of the right lower limb 111B with complaints of dilated saphenous veins on the right lower limb, her edema, fatigue and bursting pain in the calf muscles with prolonged stay on the legs, hyperpigmentation of the skin and induction of subcutaneous in the lower third of the leg on the medial surface. After ultrasound dopplerography of the veins of the lower extremities and retrograde femoral phlebography revealed the failure of the proximal valve of the femoral vein.

 Operation: microsurgical reconstruction of a failed atypical BV valve. Under epidural anesthesia after processing the surgical field, an incision in the upper third of the left thigh is 12 cm long. The skin, subcutaneous tissue, and thigh fascia are dissected. A vascular bundle and a femoral vein have been isolated. In the femoral vein, a valve is determined in the form of a spheroidal expansion of the vein, through the wall of which commissures are visible. Distal to the valve, a vascular clamp is applied to the vein and the blood is displaced in the proximal direction, when the pressure ceases with a finger, the blood rushes retrograde and freely penetrates the subvalvular space (finger test), which confirms the absence of the valve closure function. Superimposed vascular clamps on the femoral vein proximal to the valve and on the deep femoral vein. Under an operating microscope, with a magnification of 5, the vein is dissected from the level above the visible commissure by 2 mm downwards for 15 mm. The lumen of the vein is washed with saline NCL with heparin. An intravenous audit of the valve was carried out, it was revealed that there is a bicuspid valve with a commissure level difference of 10 mm, the valves are aplastic, and when trying to lift them up, the tissue is cut. Atraumatic thread 8.0 through a puncture of the wall of the vein from the outside to the inside, at a point on the side of the overlying commissure, but at the level of the underlying commissure is inserted into the lumen of the vein, the free edges of both valves are captured by a needle with an atraumatic thread, 1 mm from the free edge and at a distance from the overlying commissure sufficient to lower the cusps to the neocomissure 10 mm below the previous one and bring the length of the free edge of the cusps to the length of the semicircle of the vein. Atraumatic thread with a needle brought out of the vein wall through a puncture near the injection point. By applying 5 knots outside the wall of the vein, the flaps are pulled up to the level of neocomissure, bringing the length of their free edge to the length of the semicircle of the vein. The venotomy opening is sutured with a continuous-nodal suture. The proximal clamp is removed, the blood rushes retrograde, but does not penetrate into the subvalvular space below the closed valve flaps, the valve is consistent. Layer wound closure.

 A superficial venectomy was performed according to Beccoccus, Coquette. Stitches for wounds. Aseptic dressing. Elastic bandage of a limb.

 In the postoperative period, the patient complains of dilated veins, swelling of the limbs and pain in the calf muscles. With control ultrasound dopplerography, the valve is consistent.

 The proposed method allows to restore the closure function of the venous valve with a commissure difference of almost 4-15 mm, which we encountered in our work.

 Valves after reconstruction after the rehabilitation period withstand normal physiological stress.

 After each operation, the valve is checked using a finger test, ultrasonic dopplerography, duplex scanning. In the process, we determined the criteria for the topographic correlation of the anatomical elements of the valve and the plastic properties of the valve flaps to determine the surgical tactics of restoring the valve closure function, which are shown in the table. The table shows the data of topographic measurements of the anatomical elements of the venous valve.

 In FIG. 7 shows a photograph during the operation. In image 1, through an operating microscope with an increase in (x8), a venous valve 5 is visible after section 3 of vein 1 during its revision and measurement of the length of the commissure difference h, which reaches 12 mm.

 In FIG. Figure 8 shows the operation step — hemming of the free edge of the leaves 8 at the level of neocomissure 12, and FIG. 9 shows the operation step — completion of hemming of the free edge of the valves 8 at the level of neocomissure 12.

Claims (1)

 A method of surgical treatment of a failed valve apparatus of veins, including longitudinal section of a vein between the leaflet commissures and correction of the length of the free edge of the valve leaflets, characterized in that when the difference in levels of commissures relative to each other exceeds 4 mm, they are additionally aligned, creating new points of attachment of commissures to the vein wall using excess free edge of the valve cusps, for which valvulopexy is performed on the side of the lower commissure with the creation of neocomissure at the level of no higher commissure, either create a neocomissure, lowering the overlying commissure to the level of the underlying, or at the same time raise the lower and lower the higher commissure, creating two neocomissure on the same level.

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