RU2497458C2 - Method of extra-abdominal transference of brachiocephalic branches in hybrid treatment of aneurismas of descending aorta with extension on distal part of arc - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardio-vascular surgery. Right common carotid artery is cross-clamped. Anastomosis of right common carotid artery with synthetic prosthesis of "end-to side" type is formed. Canal is formed under pretracheal muscles. Prosthesis is passed along canal to left common carotid artery. Distal anastomosis of prosthesis with left common carotid artery of "end-to-side" type is formed. Anastomosis of left common artery with subclavian artery of "end-to-side" type is formed.

EFFECT: method makes it possible to reduce probability of thrombosis due to possibility of using maximally short synthetic prosthesis, prosthesis does not form loop, and in addition, makes it possible to restore main blood flow in left subclavian artery.

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Description

The invention relates to the field of cardiovascular surgery, in particular to a method for hybrid surgical treatment of thoracoabdominal aortic aneurysms (TAAA) and type A aortic dissection (RA). It can be used in specialized departments of cardiovascular surgery.

In patients deemed suitable for stent graft placement, the proximal and distal "necks" of the aortic aneurysm in the descending thoracic aorta must meet certain anatomical requirements for reliable fixation. Ideally, the “neck” should be represented by an unstratified strong vessel wall. The absence of a “neck” at the border of the arch and the descending aorta or the insufficiency of its length with a close proximity to the brachiocephalic arteries can create impossible conditions for endovascular intervention. In addition, with Crawford type 2 aneurysms and De Bakey type B dissections, aortic expansion can extend to the distal part of the aortic arch with the involvement of the left subclavian artery. Then, when the mouth of the left carotid artery is close, there is not enough space to fix the stent between the left carotid and subclavian arteries. To ensure a sufficient area, it is necessary to switch the left carotid and subclavian arteries. In this case, the first step before stenting is an open operation to create an “attachment zone” by switching the branches of the aortic arch (Diethrich EB, Ramaiah V., Kpodonu J., Rodriguez-Lopez J... Endovascular and hybrid management of thoracic aorta. A case -based approach, Wiley-Blackwell; 2008; 114-119, 176-181; Peterson BG, Eskandari MK, Gleason TG, Morasch MD Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pa thology. J Vase. Surg .; 2006, Mar .; 43 (3); 433-9).

The development of methods for switching the branches of the aortic arch in hybrid surgery of TAAA and type B RA is an urgent task, since hemodynamic changes in the brachiocephalic vessels in the postoperative period can lead to deficiency of blood flow in the brain and upper extremities. The search continues for the optimal method that allows the most physiologically compensate for blood flow in the arteries of the aortic arch, compromised by the installation of a stent graft. (Renders TC, Petzsch M., Ince H. et al. Intentional occlusion of the left subclavian artery during stent-graft implantation in the thoracic aorta: risk and relevance. J. Endovasc. Ther .; 2004, Dec .; 11 (6 ); 659-66).

The type of switching depends on the spread of the pathological process to the arch and the anatomical features of the discharge of the brachiocephalic arteries from the aortic arch.

There are both intracavitary methods of switching (requiring sternotomy) and extracavitary methods of switching (switching in the neck arteries).

For intracavitary switching of brachiocephalic branches, the main indication is the absence of at least one donor vessel in the neck (aneurysm of the entire arc). When at least one vessel (usually a brachiocephalic stem) departing from the aortic arch outside the zone of the proposed stenting is left, non-cavity switching is possible, which is significantly less traumatic in terms of the volume of intervention, blood loss, and duration of the operation.

If the stent can be installed below the left common carotid artery, the already known operations of the carotid-subclavian anastomosis or carotid-subclavian bypass or prosthetics are performed.

The method Diethrich E.B. is a prototype of the method of extra-cavity switching of brachiocephalic branches in the hybrid treatment of descending aortic aneurysms with spreading to the distal part of the arch in the part of cross-shunting. (Diethrich E.V., Ramaiah V., Kpodonu J., Rodriguez-Lopez J.-Endovascular and hybrid management of thoracic aorta. A case-based approach, Wiley-Blackwell; 2008; 171-175), which sleepily produces - sleep prosthetics from the right to the left with a synthetic prosthesis of 8 mm with the formation of proximal and distal anastomoses "end to side".

However, the known method has significant disadvantages:

1. A synthetic prosthesis is performed along the sternocleidomasticular arches, changing direction under the sternum handle. This increases the length of the synthetic prosthesis, which increases the possibility of thrombosis.

2. The large length of the prosthesis and the arched arrangement of the prosthesis creating a twofold change in the direction of the blood flow direction by almost 180 ° (in the proximal anastomosis and under the sternum handle) create the prerequisites for slowing down the blood flow velocity in the prosthesis and, as a result, reducing the volume of perfusion in the left common carotid artery with a risk of developing acute cerebrovascular accident.

3. Blood flow in the left subclavian artery is not restored, which in some cases leads to decompensation of blood circulation in the left upper limb.

The objective of our proposed method of extra-cavity switching of brachiocephalic branches in the hybrid treatment of descending aortic aneurysms with spreading to the distal part of the arch is to increase the effectiveness of treatment of TAAA and type B RA by reducing the frequency of neurological disorders of the near and distant postoperative period associated with hypoperfusion of the left hemisphere of the brain, thrombosis synthetic grafts and prevention of circulatory decompensation of the left upper limb.

With the method of extra-cavity switching of brachiocephalic branches in the hybrid treatment of descending aortic aneurysms with spreading to the distal part according to the invention, the arches access both common carotid arteries, when the right common carotid, internal carotid artery and external carotid artery are applied, anastomoses with a synthetic prosthesis of the “end” type to the side ”, form a channel under the pretracheal muscles, carry out a prosthesis along the channel to the left common carotid artery at a minimum distance, perform a distal anastomosis, otosis with the left common carotid artery according to the type “end to side”, anastomosis of the carotid artery with the subclavian artery is performed according to the type “end to side” (Fig. 1 - illustrates the scheme of the method of extra-cavitary switching of brachiocephalic branches in hybrid treatment of descending aortic aneurysms with spread to distal part of the arc).

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 advantage of the proposed carotid-carotid bypass surgery is that the proximal anastomosis of the prosthesis with the right common carotid artery is superimposed at an angle of 35-40 ° with respect to the blood flow and the prosthesis is performed behind the pretracheal muscles. the length of the prosthesis is as short as possible and the prosthesis does not make a large loop. As a result of the proposed method, the main blood flow in the left subclavian artery is simultaneously restored.

The following example illustrates the application of the proposed method of extracavitary switching of brachiocephalic branches in the hybrid treatment of descending aortic aneurysms with spreading to the distal part of the arch in a patient with severe combined and concomitant pathology. At the same time, the absence of neurological symptoms and hypoperfusion of the brachiocephalic arteries in the postoperative period was noted. The successful completion of the first stage predetermined a good result of hybrid surgical treatment of type B aortic dissection. The patient has a smooth postoperative period and a minimum recovery period after treatment.

Patient Z., 66 years old. Diagnosis: Connective tissue dysplasia. Atherosclerosis. Aortic dissection type B with transition to the iliac arteries. Thoracoabdominal type 2 aortic aneurysm (Crawford). IHD: a painless form, postinfarction cardiosclerosis. Condition after autologous coronary artery bypass grafting of the anterior interventricular artery, dull edge branch, posterolateral branch, posterior interventricular artery.

From the anamnesis: for a long time notes blood pressure rises to 180/100 mm Hg, with max up to 200/100 mm Hg With a planned ultrasound, an abdominal aortic aneurysm of up to 4.5 cm was diagnosed. Dynamically observed. When examined at the Institute. N.I.Sklifosovsky, where, according to CT data, type 3 aortic dissection was diagnosed, Thoracoabdominal aortic aneurysm. Then he entered the RSCH RAMS for surgical treatment. In the hybrid treatment of thoracoabdominal aneurysm with spreading to the distal part of the arch, the method of extra-cavity switching of brachiocephalic branches was applied. Standard access allocated right OCA, ICA, NSA with a diameter of 9 mm, 6 mm, 5 mm, respectively. Highlighted the left OCA, ICA, with a diameter of 9 mm, 6 mm, respectively. Heparin 5000 units in \ in. Right OCA was pinched. An anastomosis was formed between the prosthesis and the OCA according to the “end to side” type with a continuous entwining suture with a 5/0 prolet thread. Prevention of material and air embolism. Clips removed. The prosthesis was performed under the muscles of the neck to the left OCA. Clips on the left OCA are superimposed. Arteriotomy Repeated washing of the artery with saline. An anastomosis was formed between the prosthesis and the OCA on the left end-to-side type with a continuous 5/0 suture sewing with a continuous thread. Prevention of material and air embolism. The start of blood flow. The ripple in the reconstruction is distinct. The clamping time of the left OCA is 39 minutes. From the left supraclavicular access, the left subclavian artery is highlighted throughout. The distinguished common left carotid artery is maximally proximal ligated and cut off distally to the ligation with preliminary compression of the distal section. Formed anastomosis of the carotid artery with subclavian type "end to side" atraumatic thread "prolene" 5.0. The ripple in the reconstruction is distinct. Hemostasis. The wounds were sutured in layers leaving rubber graduates.

A week later, stenting of the thoracic aorta with the Mediantronic Valiant AMF4040C200TE system.

The postoperative period was uneventful, sutures with no signs of inflammation.

Claims (1)

The method of extra-cavity switching of the brachycephalic branches in the hybrid treatment of the descending aortic aneurysm with spreading to the distal part of the arch, including the extraction of the right and left common carotid arteries, carotid-carotid prosthetics from right to left with a synthetic prosthesis and the formation of proximal and distal end-to-side anastomoses, characterized in that compress the right common carotid artery, form an anastomosis of the right common carotid artery with a synthetic prosthesis of the type "end to side", form a channel under the pretracheal and muscles, a prosthesis is carried out along the channel to the left common carotid artery, a distal anastomosis of the prosthesis with the left common carotid artery is of the end-to-side type, an anastomosis of the left common carotid artery with the subclavian artery of the end-to-side type is formed.

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