RU2514536C1 - Method for formation of subclavian-shoulder fistula - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: what is involved is forming an end-to-side venous anastomosis of a synthetic prosthesis with a subclavian vein on a border with an axillary vein. The prosthesis is laid as linearly as possible under the skin of a deltoid region and a shoulder along an anteromedial surface; that is followed by forming an end-to-side arterial anastomosis of a synthetic prosthesis with a brachial artery along an anteromedial surface of the shoulder.

EFFECT: method enables creating the favourable conditions for fistula outflow ensured by low hydrostatic pressure in accessible veins of an upper limb; it does no cause venous hypertension due to the minimal number of inflows, enables creating more extended section of the prosthesis for puncturing.

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Description

The invention relates to medicine, to a method for forming vascular access from a synthetic prosthesis in patients undergoing chronic hemodialysis, who require blood filtration.

The well-known brachiocephalic fistula described in the monograph “Angiosurgical aspects of preparing the patient for hemodialysis” by V.Yu. Kleiza and B.E.Dainis, Vilnius 1980, p. 138. Access is formed on the shoulder in the form of a loop using its own plastic material (venous graft). The brachial artery is isolated either from a 5-6 cm incision in the lower third of the shoulder along the medial groove of the biceps muscle, or from a section in the cubital fossa 5-6 cm long medial to the tendon of the biceps brachii. Next, a 2.5-3 cm long incision along the deltoid-pectoral groove, the fascia of the same name is opened, the deltoid muscle is laterally removed, the pectoral medially, the head vein is secreted. An end-to-side venous anastomosis is formed, the venous graft is placed in a subcutaneous tunnel, optimal for further puncture, more often along the anterior-medial surface of the shoulder. The proximal anastomosis is formed with the brachial artery by the type of "end to side".

Known shoulder-brachial fistula described in the monograph by Moisyuk Ya.G., Belyaev A.Yu., Inozemtseva A.S., Shilo V.Yu. “Permanent vascular access for hemodialysis: current trends,” 2005, pp. 67-69. Access is formed on the shoulder in the form of a loop using a synthetic prosthesis. The brachial artery is secreted from a 5–6 cm long incision in the lower third of the shoulder along the medial sulcus of the biceps muscle. An incision in the upper third of the shoulder along the medial groove of the biceps muscle at the border with the axillary region, the brachial vein stands out at the border with the axillary vein. A venous anastomosis of the “end to side” type is formed, a synthetic prosthesis is placed on the front surface of the shoulder in the form of a “suitcase handle”. An arterial anastomosis of the type "end to side" is formed.

The disadvantages of the closest analogue are: the possibility of the formation of venous hypertension in the upper limb due to retrograde reflux of arterial blood into the venous inflows of the deep system, greater peripheral resistance of the venous segment from the venous anastomosis to the right atrium, which complicates the outflow of blood, a shorter segment for punctures, inconvenience for the patient and personnel during the puncture due to the non-linear shape of the laid prosthesis on the shoulder (in our invention, the prosthesis is straight from the lower the shoulder artery to the junction of the clavicle with the acromion of the scapula), in some cases, the diameter of the brachial vein is insufficient to form AVF (in our invention, the subclavian vein is larger than the brachial vein, and it is almost always possible to form AVF with an adequate artery), venous anastomosis, which creates conditions for turbulent blood flow, intimal hyperplasia followed by AVF thrombosis (in our invention, the prosthesis in the venous anastomosis is connected to the subclavian vein without bending at an angle ohm 70-80 degrees).

The objective of the invention is to create an adequate long-functioning alternative vascular access in patients with the lack of adequate arterial and venous material on the upper limb, which will function for a long time, give a minimum number of complications, be comfortable for the patient.

The technical result consists in the fact that the method allows to create favorable conditions for the outflow of blood through the fistula due to the lowest hydrostatic pressure in the easily accessible veins of the upper limb, does not lead to venous hypertension due to the minimum number of inflows, and allows to obtain a more extended section of the prosthesis for puncture.

The method of forming vascular access from a synthetic prosthesis, including the formation of a venous anastomosis, laying of the prosthesis, the formation of an arterial anastomosis, characterized in that the venous anastomosis is formed with the subclavian vein at the border with the axillary vein, the prosthesis is laid as straight as possible under the skin of the deltoid region and shoulder along the anterior medial surface, arterial anastomosis form along the front-medial surface of the shoulder.

The method is implemented as follows.

The patient is placed on the operating table, the operated upper limb is retracted 90 degrees from the longitudinal axis of the body, and a roller is placed in the interscapular space for maximum abduction of the shoulder girdle. The brachial artery is extracted from a section 5-6 cm long in the lower third of the shoulder along the medial sulcus of the biceps muscle. Then the subclavian vein is extracted. To do this, an incision is made in the subclavian region in the projection of the neurovascular bundle 2 cm lower at an angle of 10-20 degrees relative to the horizontal axis of the clavicle. The acute angle of the cut axis should be facing the sternal end of the clavicle. The length of the incisions is determined by the constitution of the patient. The axillary vein stands out on the border with the subclavian vein. Anastomosis of a synthetic prosthesis with subclavian vein is formed by the type of "end to side". The venous anastomosis is formed by the subclavian vein at the border with the axillary vein so that the venous anastomosis is as close as possible in the superior vena cava, where the pressure is from 0 to 5 mm Hg. - a sufficient rate of volumetric blood flow, since a distal anastomosis forms at the border of the axillary and subclavian veins, i.e. in the place where the vein has a minimum number of tributaries, the pressure in the vein has a minimum value of up to 12 mm Hg The remaining veins of the upper limb, which are located in the chest, have less venous pressure, but they are inaccessible. The more distally the venous anastomosis is formed, the more inflows, the farther from the heart, the greater the venous pressure, the smaller the gradient between the arterial and venous anastomosis of the formed fistula, the lower the blood flow velocity, the greater the resistance and the higher the risk of thrombosis. The prosthesis is placed in the subcutaneous tunnel as straight as possible in the optimal position for further puncturing in the deltoid region, on the front surface of the shoulder is placed on the front-medial. In the lower third of the shoulder, the prosthesis in the form of a loop bends and fits to the selected brachial artery. Form an arterial anastomosis. Anastomosis of a synthetic prosthesis with a brachial artery is formed by the type of "end to side". Unlike the closest analogue, we get a longer stretch of the prosthesis for puncture. Then, blood flow is started, bleeding is stopped, and skin wounds are sutured.

The method is distinguished by the simplicity of the operation, cosmetic, hygiene and convenience for the patient during dialysis.

Clinical examples

Example 1. Patient C.S.Z., 36 years old, terminal chronic renal failure 3A according to Ryabov developed due to the progression of chronic glomerulonephritis. Renal replacement therapy with peritonial dialysis has been started. In connection with the dislocation of the peritonial catheter, after 1 month, it was decided to transfer the patient to hemodialysis. A temporary double-lumen catheter was installed in the right subclavian area for hemodialysis. Then, an examination was started to form a permanent vascular access. When examining a patient, superficial veins were not suitable for the formation of distal arteriovenous fistula due to the fact that he had previously used drugs in the form of intravenous injections in the upper and lower extremities. Ultrasound of veins and arteries of the upper and lower extremities was performed:

1. Head vein 1.5 mm, main vein 1.8 mm on the forearm in the lower third on both sides.

2. Radial artery 1.8 mm on the forearm in the lower third on both sides.

3. Large saphenous vein on the right up to 5 mm, on the left 3.9 mm on the thigh on both sides.

4. Cubital collectors not more than 3.4 mm on both sides.

5. brachial artery 4.0 mm on the shoulder in the lower third of the two sides with a volumetric blood flow from 52 to 64 ml per minute.

6. Subclavian vein 6.4 mm on both sides.

In connection with the obtained ultrasound parameters, it was decided to audit the cubital collector on the right, the saphenous vein on the right, then form a loop arteriovenous fistula on the forearm on the right. During the audit, the cubital collector on the right is 3 mm soft, passable, the brachial artery is 6 mm in diameter, soft, passable, the pulsation is distinct. BPV on the right during the audit with a diameter of 6 mm is occluded. Given the intraoperative picture, it is impossible to form a loop arteriovenous fistula on the forearm on the right. It was decided to form the shoulder-shoulder-shoulder or shoulder-subclavian fistula with a linear synthetic prosthesis of 6 mm diameter by Gore-tex company, since the subclavian catheter is installed in the right subclavian fistula. The option of forming vascular access on the thigh was rejected due to the fact that this type of fistula has more complications and provides more inconvenience for the patient compared to fistulas on the upper extremities.

When revising the vascular bundle in the lower third of the left shoulder brachial artery 6 mm, the brachial vein is represented by two trunks 4 mm each. Due to the fact that the brachial veins of insufficient diameter to ensure adequate venous outflow, it was decided to form the brachial subclavian fistula (PPF) on the right. Highlighted subclavian vein in the subclavian region on the right with a diameter of 8 mm, suitable for the formation of PPF. The formation of this fistula by the above method is completed.

Example 2

Patient B.L.N., 70 years old, terminal chronic renal failure 3A according to Ryabov developed as a result of urolithiasis and secondary pyelonephritis. The patient started renal replacement therapy with hemodialysis after installing a temporary double-lumen catheter in the right subclavian vein. Next, the patient is formed by Cimino type AFF on the right. This access functioned for 11 months, after its thrombosis formed a new AVF of the Cimino type on the left. The fistula on the left was thrombosed in the early postoperative period and was not exploited. A temporary double-lumen catheter was inserted into the right internal jugular vein. The patient had exhausted the possibility of forming distal fistulas after two of these operations. To form an adequate vascular access, ultrasound diagnostics of arteries and veins of the upper and lower extremities was performed:

1. In the middle third of the forearm, the head vein is occluded on both sides, the main vein is 1.4 mm on the right, 1.6 mm on the left.

2. In the middle third of the forearm, the radial artery on the right is 2.1 mm, 3.4 mm on the left.

3. Large saphenous vein no more than 2.6 mm on both sides.

4. Cubital collectors are absent on both sides.

5. The brachial artery on the shoulder in the lower third is 3.3 mm on the right, 4.3 mm on the left with a volumetric blood flow rate of 50 ml per minute on the right, 400 ml per minute on the left.

6. Subclavian vein 7, 6 on the right, 8, 6 on the left.

Based on the data obtained, it is not possible to form autovenous AVF on the upper extremities. The variant of formation of vascular access on the thigh was rejected for the same reason as in the first patient. It was decided to form the shoulder-subclavian fistula with a linear synthetic prosthesis of 6 mm diameter by Gore-tex company on the left, as arteries and veins on the right are worse than on the left. The formation of this fistula by the above method is completed.

Claims (1)

The method of forming vascular access from a synthetic prosthesis, including the formation of a venous anastomosis, laying of the prosthesis, the formation of an arterial anastomosis, characterized in that the venous anastomosis is formed with the subclavian vein at the border with the axillary vein, the prosthesis is laid as rectilinearly as possible under the skin of the deltoid region and shoulder along the anteromedial surface, arterial anastomosis form on the front-medial surface of the shoulder.