RU2312615C1 - Method for surgical treatment of high aortic occlusions - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: it is necessary to fulfill thoracophrenopararectal access towards aorta in the 8^th intercostals area; for this purpose one should start the incision from scapular line to finish it not reaching inguinal ligament, then comes aortic mobilization in inferior-thoracic department; one should apply a clamp onto aorta parietally, moreover, being above all visceral branches to form proximal anastomosis of the main branch of bifurcation prosthesis and aorta. Moreover, anastomosis should be formed according to "end-to-side" type in aortic inferior-thoracic department. The innovation enables to simplify the process of surgical therapy of high aortic occlusions, remove the causes of post-surgical embolic and thrombotic complications, improve the nearest results of operation and decrease the number of complications.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, in particular to surgery, and can be used in surgical treatment of high aortic occlusion, including with damage to the renal arteries.

A known method of surgical treatment of high aortic occlusion, in particular, a method of bifurcation aortic femoral prosthetics at the level of the renal arteries with high occlusions (Belov Yu.V. Guide to vascular surgery. M .: DeNovo, 2000, p.111), in which the operation is carried out as follows way: perform thoracophrenopararectal access to the aorta, and a skin incision is performed on 7-8 intercostal space, starting from the rear axillary line and ending without reaching 5 cm to the inguinal fold. Next, the infrarenal aorta is isolated, after exposing the aorta from the level of the inferior mesenteric artery to the place of discharge of the superior mesenteric artery, the left renal artery and the mouth of the left lumbar arteries are mobilized, the lumbar, left renal artery is pinched sequentially, the aorta is immediately lower or higher than the superior mesenteric artery by clamping transverse to arteries and aorta. Then produce a longitudinal aortotomy along the left wall of the aorta and resection of the aorta at a distance of 3 cm distal to the left renal artery. The edges of the aorta are diluted with tweezers and a spatula from the lumen of the aorta throughout the incision to remove thrombotic and ulcerative necrotic atheromatous masses.

After washing the wound of the aorta, it is sutured from the upper angle down to the transverse incision of the aorta, the clamp of transverse clamping of the aorta is shifted below the renal arteries, other previously pinched arteries are released, and blood circulation in the kidneys and lumbar arteries is restored. Next, the proximal anastomosis of the main branch of the prosthesis with the aorta is started: the main branch of the bifurcation prosthesis cut transversely is sewn into the free end of the aorta under the renal arteries. Then, first, the left jaw of the prosthesis and the formation of its anastomosis with the femoral artery are carried out, and then the right jaw of the prosthesis and the formation of the anastomosis with the right femoral artery are performed.

The disadvantages of this method are as follows.

The need to isolate the infrarenal section of the aorta, in which great technical difficulties may arise due to the presence of a pronounced process of periaortic, retroperitoneal fibrosis, is also a risk of damage to large venous trunks (lumbar plexuses and the inferior vena cava) with heavy bleeding and massive blood loss. The initial transverse clamping of the clamp on the aorta above the renal arteries completely blocks the blood flow through the renal arteries, and therefore, to avoid ischemic damage to the kidneys as a result of thermal ischemia, clamping of the aorta should not exceed 30-40 minutes. In addition, when the clamp is transferred from the aorta above the renal arteries to the aorta below the renal arteries, there is a risk of renal artery embolism with atheromatous masses from the aorta.

The infrarenal part of the aorta is the most pathologically altered - it is characterized by: ulcerative necrotic atheromatosis, severe calcification, aortic wall failure (large thinning after intrombectomy and partial decalcification), stenosis of the infrarenal segment of the aorta, which is a serious obstacle to the full implementation of the anastomosis of the main branch "End to end" with the aorta.

The objective of the invention is to simplify the process of operating high aortic occlusions, eliminating the causes of postoperative embolic and thrombotic complications, improving the immediate results of the operation, reducing the number of complications.

The problem is solved due to the fact that in the method of surgical treatment of high aortic occlusion, including thoracophrenopararectal access to the aorta in the 8th intercostal space, mobilization of the aorta, clamping on the aorta and proximal anastomosis of the main branch of the bifurcation prosthesis with the aorta, thoracophrenopararectal access from the scapular line, then the aorta is mobilized in the lower thoracic region, the clamp is applied parietally above all visceral branches, and the proximal anastomosis is performed as flat on the side ”in the lower thoracic aorta.

The proposed method uses standard surgical access to the aorta, but for better exposure of the aorta, it is performed in the 8 intercostal space, starting from the scapular line, which makes it possible to open the pleural cavity wider and provide additional manipulation on the lower thoracic aorta.

Isolation of the infrarenal section of the aorta is not performed, and no manipulations are performed in this section, as in the most pathologically altered and dangerous in terms of damage to adjacent atomic structures.

Parietal clamping in the lower thoracic region above all visceral branches allows preserving perfusion of all visceral branches (celiac trunk, superior mesenteric artery, renal arteries), in addition, perfusion of critical intercostal arteries supplying the spinal cord is preserved.

The time of application of the anastomosis is not limited, since there is no stoppage of blood circulation in the vital arteries and thermal organ ischemia.

The aorta in this section is almost intact, there is no calcification, ulcerative necrotic atheromatosis, there is no high risk of embolism by atheromatous masses and there is no stenosis.

The proposed method for the surgical treatment of high aortic occlusions is illustrated by drawings, in which Fig. 1 shows the lower thoracic aorta with parietal (lateral) clamping in the lower thoracic aorta above all visceral branches and with longitudinal aortotomy, and Fig. 2 shows a proximal anastomosis of the main branch of the bifurcation prosthesis with aorta.

The proposed method for the surgical treatment of high aortic occlusion is as follows. The operation is performed under general anesthesia.

The operation begins with a revision of the femoral arteries according to the traditional method.

Then, extended thoracophrenopararectal access to the aorta is performed in the 8 intercostal space, starting from the incision from the scapular line and ending without reaching 5 cm to the inguinal fold (not shown), aorta 1 is detected and mobilized in the lower thoracic region. To perform bypass surgery, the blood flow in this section of the aorta 1 is partially blocked by parietal squeezing of the aorta 1 above all visceral branches, including the celiac trunk 2, superior mesenteric artery 3 and renal arteries 4, with an aortic clip 5 with curved jaws.

The preparation of the main jaw 6 of the prosthesis 7 is carried out as follows: the end of the main jaw 6 of the anastomosed prosthesis 7 is stretched in length, squeezed along the side surfaces and an edge is cut along the arc, thereby forming a “cobra head” type of incision.

After an aortotomy with a scalpel, angular scissors form a rounded window 8 for the proximal anastomosis.

Anastomosis of the main branch 6 of the prosthesis 7 with the aorta 1 of the type "end to side" is performed. First, the left semicircle 9 of the anastomosis is sewn, then the right semicircle 10 of the anastomosis is formed. The shape of the anastomosis takes the form of a circle.

After completion of the anastomosis, the clamp 5 from the aorta 1 is removed, while the bifurcation branches 11 and 12 of the prosthesis 7 are clamped by separate clamps (not shown). Then, tunneling is carried out - first, the left jaw 11, and then the right jaw 12 using a device for tunneling to the corresponding femoral arteries and perform distal anastomoses of the jaws 11 and 12 with the corresponding femoral arteries, after which the clamps are removed from the jaws 11 and 12, the blood flow through the aorto-femoral prosthesis 7 and perform suturing of surgical wounds.

Example 1

Patient Ch., 59 years old, was admitted to OKB No. 1 in Yekaterinburg (medical history No. 4719) with complaints of: intense pain in the legs, mainly on the right when walking up to 100 meters, passing at rest; parasthesia, chilliness of the feet; high blood pressure up to 200/110 mm RT. Art, accompanied by headache, dizziness.

From the anamnesis it is known that he considers himself a patient since 1996, when the first fatigue of the lower extremities with prolonged walking and the chilliness of the feet first appeared. The progression of the disease in 2001 led to the appearance of symptoms of "intermittent" claudication of the lower extremities. Treatment with conservative therapy did not work. Arterial hypertension since 1997, corrected by drug therapy, working blood pressure of 140/90 mm RT. Art.

An objective examination revealed: the feet are cold, pale; pulsation on the common femoral, popliteal, posterior tibial, anterior tibial arteries on both sides is not determined, nor is pulsation of the infrarenal aorta determined.

Data from laboratory parameters, fluorography, ultrasound cardiography, electrocardiograms, ultrasound examination of the abdominal cavity and kidneys - without pathology.

An angiographic study revealed: aortic occlusion immediately below the renal arteries, 70% stenosis of the left renal artery, occlusion of the left superficial femoral artery throughout the upper third of the thigh, patency of the vessels of the thigh and lower leg on the right is preserved, the distal vascular bed is also passable.

Based on the tests, the diagnosis was made: atherosclerosis, high aortic occlusion, left upper surface femoral artery occlusion, stage II B chronic lower limb ischemia (HINC), left renal artery stenosis, vasarenal hypertension syndrome 2 functional class.

On March 03, 2003, the patient underwent the following operation: descent-aorto-hip-bifurcation bypass, autovenous plastic of the left renal artery with reimplantation into the main branch of the prosthesis, prosthetics of the superfemoral artery to the left above the gap of the knee joint.

The progress of the operation.

A revision of the femoral arteries from vertical sections in the upper third of the hips was performed. It was revealed that on the right the superficial femoral artery and deep femoral artery are passable, and on the left the superficial femoral artery is occluded, and the deep femoral artery is passable. To the left of the access in the lower third of the thigh, access and revision of the superficial femoral artery was made, as a result of which it was revealed that the latter was passable and suitable for reconstruction.

An extended thoracophrenolumbotomy was performed in the 8th intercostal space on the left, the descending section of the thoracic aorta 1 and the abdominal aorta 1 with the left renal artery 4 were isolated, the renal artery 4 was occluded for two segments. The infrarenal section of the aorta is occluded immediately under the renal arteries 4 and has a stony density. Marked pariaortic fibrosis, retropreitoneal fibrosis and massive calcification of the abdominal aorta 1 are noted, which makes it extremely difficult to adequately mobilize the infrarenal aorta 1.

The descending thoracic aorta is 1 intact. The diameter of the aorta is 16 mm. Periosteal aorta 1 was performed in the lower thoracic region, above the diaphragm, while maintaining blood flow through the intercostal, renal 4 and visceral arteries. Aortotomy and proximal anastomosis of the main branch 6 of the bifurcation prosthesis 7 of size 16x8x8 in the side of the aorta with a 2/0 Proline thread were performed. Blood flow is on. The diameter of the aorta 1 and prosthesis 7 correspond to the formed anastomosis. The clamping time of the aorta 1 was 15 minutes.

The left 11 and right 12 branches of the prosthesis 7 are led out to the femoral arteries through the formed tunnels in the retroperitoneal tissue, distal anastomoses of the bifurcation branches 11 and 12 with the end-to-side femoral arteries with thread “Prolen” 5/0 are made, blood flow is started. A distinct pulsation of the vessels is observed, the anastomoses are tight.

A fragment of the large saphenous vein was taken from the left thigh. Resection of the left renal artery 4 was performed with autovenous plasty and reimplantation into the main jaw 6 of the prosthesis with thread “Proline” 6/0.

The prosthetic femoral artery was prosthesed with a distal anastomosis of the Gore-Tex 8 prosthesis in the lateral artery and proximal anastomosis of the prosthesis in the lateral bifurcation left branch 11 in the upper third of the thigh. Blood flow is started, the pulsation of the vessels is distinct.

Hemostasis was performed, drainages were placed into the pleural cavity and retroperitoneal space, and sutures were placed on the wounds.

Operation time 5 hours 20 minutes.

The postoperative period was uneventful. The patient is extubated 20 hours after surgery. Drainages were removed on the 2nd day with control radiography. Control angiography revealed a good contrast of the descending thoracic aorta, bifurcation aorto-femoral shunt, implanted left renal artery and femoral-popliteal shunt with filling of the distal channel. Pulsation of the arteries of the lower extremities is observed at all levels.

In satisfactory condition, the patient was discharged on the 14th day after the operation. 3 months after the operation, the patient began his previous work. Examined after 6 months. There are no complaints, there are no phenomena of chronic ischemia of the lower extremities, pulsation of the arteries of the lower extremities at all levels, remission of hypertension is observed.

Example 2

Patient L., 48 years old, was admitted to OKB No. 1 in Yekaterinburg (medical history No. 26236) with complaints of: intense pain in the legs and feet when walking up to 20-50 meters, which is at rest; paresthesia and chilliness of the feet.

From the anamnesis it is known that the patient considers himself since 1999, when there was increased fatigue of the lower extremities with prolonged walking, and chilliness of the feet. The progression of the disease in 2000 led to the appearance of symptoms of "intermittent" claudication of the lower extremities. Treatment with conservative therapy did not work. He has been under the supervision of a rheumatologist since 1990 with a diagnosis of nonspecific artery arteritis, currently minimal activity.

An objective examination revealed: the feet are cold and pale, lack of pulsation on the common femoral, popliteal, posterior tibial, anterior tibial arteries on both sides, and pulsation of the infrarenal aorta is also not determined.

Data of laboratory parameters, fluorography, ultrasound cardiography, electrocardiogram, ultrasound examination of the abdominal cavity and kidneys - without pathology.

Rheumatological tests - the lack of activity of the process. An angiographic study revealed: aortic occlusion 1 immediately below the renal arteries 4, renal arteries 4 without pathology, the vessels of the hips and lower legs on both sides are passable.

Based on the tests, the diagnosis was made: nonspecific aortoarteritis, minimal activity, high aortic occlusion. Chronic lower limb ischemia (HINC) II stage II.

September 10, 2002 the operation was performed.

The progress of the operation.

A revision of the femoral arteries was made from vertical sections in the upper third of the hips: the common femoral artery, superficial femoral artery, deep femoral artery on both sides are passable and suitable for reconstruction.

An extended thoracophrenolumbotomy was performed in the 8th intercostal space on the left, the descending thoracic and abdominal aorta 1 were distinguished. The infrarenal aorta 1 was occluded immediately under the renal arteries 4 and had a stony density. Marked periaortic fibrosis, retroperitoneal fibrosis and calcification of the infrarenal aorta 1 are noted, which complicates the mobilization of the infrarenal aorta 1.

Aorta 1 is isolated in the lower thoracic region. The diameter of the aorta is 18 mm. A lateral aortic 1 squeezing was performed in the lower thoracic region, above the diaphragm, with preservation of blood flow through the intercostal, renal 4 and visceral arteries, aortotomy. At the same time, pronounced subintimal hyperplasia and parietal thrombi were revealed in the lumen. Blood clots were removed and the aortic lumen was washed. Formed proximal anastomosis of the main branch 6 of the bifurcation prosthesis 7 with a size of 18x9x9 in the side of the aorta with the thread "Proline" 2/0. Blood flow is on. The diameter of the aorta 1 and prosthesis 7 correspond to the formed anastomosis. Aortic clamping time 1 was 18 minutes. The left 11 and right 12 branches of the prosthesis 7 are led to the femoral arteries through the formed tunnels in the retroperitoneal tissue. Distal anastomoses of bifurcation branches 11 and 12 with end-to-side femoral arteries at the level of their bifurcation with a Proline 5/0 thread and blood flow were performed. A distinct pulsation of the vessels is observed, the anastomoses are tight. Performed hemostasis, installed drainage into the pleural cavity and retroperitoneal space. Stitched to the wounds.

Operation time 3 hours 30 minutes.

The postoperative period was uneventful. The patient is extubated 8 hours after surgery. Drainages were removed on the first day after surgery, with control radiography. When control angiography revealed a good contrast of the descending thoracic aorta, bifurcation aorticos femoral shunt with filling of the distal bed. Pulsation of the arteries of the lower extremities is observed at all levels.

The patient in satisfactory condition was discharged 12 days after surgery. Examined after 6 months. There are no complaints, there are no phenomena of chronic ischemia of the lower extremities, pulsation of the arteries of the lower extremities at all levels is determined, there is no activity of nonspecific aortoarteritis.

The proposed method for the surgical treatment of high aortic occlusions (descent-aorto-hip-bifurcation bypass) has the following advantages compared to the known method:

the process of operating high aortic occlusion is simplified, because no manipulations are carried out in the infrarenal part of the aorta, in particular, a section of the aorta with high occlusion is not exposed to isolation, longitudinal aortotomy in order to extract thrombotic and ulcerative necrotic atheromatous masses and all manipulations related to this are not performed (moving the clamp on the aorta, its suturing), which helps to eliminate the causes of postoperative embolic and thrombotic complications,

the risk of ischemic damage to internal organs is reduced and the quality of the proximal anastomosis is improved, because the operation is performed not in the infrarenal part of the aorta, as the most pathologically altered and dangerous in terms of damage to adjacent anatomical structures, but in the lower thoracic part of the aorta, and parietal clamping on the aorta allows you to save blood flow through all visceral branches, lumbar arteries, resulting in the formation of proximal the anastomosis is not limited, the anastomosis is superimposed on a healthy section of the aorta, where there are no pathological changes, which also improves the quality of the anastomosis and reduces a claim of post-operative complications.

Claims (1)

A method for the surgical treatment of high aortic occlusions, including thoracophrenopararectal access to the aorta in the 8th intercostal space, mobilization of the aorta, clamping on the aorta and the formation of a proximal anastomosis of the main branch of the bifurcation prosthesis with the aorta, characterized in that they perform thoracophrenopararectal access to the aortic, for this, the incision is started the lines and end it, not reaching the inguinal ligament, then they mobilize the aorta in the lower thoracic region, the clamp on the aorta is applied parietally, and you e all visceral branches further form the proximal anastomosis "end-to-side" in the lower thoracic aorta.

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