RU2560774C1 - Method for exercising approach for prosthetic implantation into thoracic aorta - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin is incised into a first intercostals space on the right. The muscles are transected by sharp dissection. A first rib is resected. A parietal pleura is detached by blunt dissection in the lateral direction with opening an anterior wall of a brachiocephalic trunk. Two concentric adventitial purse sutures are applied on the anterior wall of the brachiocephalic trunk. The suture centre is punctured. The main stage of the surgery is followed by haemostasis by tightening the purse sutures tight successively.

EFFECT: method enables performing thorasis aorta stenting if having no access through femoral or external iliac arteries.

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Description

The invention relates to medicine, namely to surgical approaches used in vascular surgery for the installation of aortic endoprostheses.

To install aortic endoprostheses, access through the femoral artery is used. An incision is made transversely immediately below the inguinal ligament. After mobilization and proximal control, the artery is punctured, a conductor with a diameter of 0.035 inches is pulled to the level of the thoracic aorta, and an introducer is installed. If in the process of preoperative preparation it turns out that the femoral artery is too small, affected by some disease or has increased tortuosity, then the external or common iliac arteries are used for access. In this situation, the incision is performed proximal to the inguinal fold. Puncturing of the external iliac artery is performed in the same way as with the described femoral approach (Vascular surgery according to Khaimovich. Edited by E. Asher. Volume 2. M., BINOM. Laboratory of Knowledge, 2010, 529 pp., S.30-31) . One of the important conditions for the success of this stage of the operation is the presence of a femoral or external iliac artery of sufficient diameter, more than 7.7 cm (22F).

The disadvantage of these accesses is the impossibility of performing the operation in a number of cases: the patient’s young age, small diameter arteries, the presence of metal structures in the pelvis and upper third of the thigh in patients with combined trauma, occlusive lesions of the aorto-iliac segment, pathological tortuosity of the iliac arteries.

The technical result achieved by the invention is to expand the arsenal of tools related to vascular access for implantation of endoprostheses in the thoracic aorta.

The claimed technical result is achieved in the access method for implantation of endoprostheses into the thoracic aorta, including arterial puncture, according to which a skin incision is made in the first intercostal space on the right, the muscles cross sharply, the first rib is resected, the parietal pleura is laterally blunt, exposing the anterior wall of the brachiocephalic trunk, impose two concentric purse string adventitious sutures on the front wall of the brachiocephalic trunk and in the center of the purse string suture perform a puncture after completion of the main apa sequential operations carried out by tightening hemostasis purse string sutures.

The brachiocephalic trunk has a diameter sufficient to conduct an introducer sheath and insert an endoprosthesis into the thoracic aorta. Performing a skin incision in the first intercostal space on the right, sharp dissection of the muscles, resection of the first rib and lateral exfoliation with a blunt parietal pleura provide extrapleural access to the brachiocephalic trunk necessary for further manipulations. The application of two concentric purse string adventitious sutures on the anterior wall of the brachiocephalic trunk and the puncture in the center of the purse string suture completes the formation of access for implant implantation. Sequential tightening of purse string sutures after the completion of the main stage of the operation allows reliable hemostasis without resorting to clamping the vessel.

The method was tested on 10 corpses, as a result of which it was found that access through the brachiocephalic trunk in all cases allows the implant to be implanted due to the sufficient diameter of the brachiocephalic trunk.

The drawing shows a diagram of access.

The method is carried out, for example, as follows.

Under endotracheal anesthesia, a skin incision is made in the first intercostal space on the right, the muscles cross sharply, the first rib 1 is resected, the parietal pleura is laterally blunt, the anterior wall of the brachiocephalic trunk 2 is exposed. Two concentric purse string adventitious sutures are formed on the front wall 3. The threads are taken holders. In the center of 4 purse string sutures 3, the artery is punctured with an angiographic needle. Further, according to the standard method, the implant is implanted (stent graft) into the thoracic aorta. At the final stage of the operation, the conductor is removed, two purse string sutures are sequentially tightened until hemostasis is achieved. Suture the muscles, fascia, skin.

The method is illustrated by a clinical example.

Patient I., 22, was admitted to the Department of Vascular Surgery with a diagnosis of Road Trauma. Combined injury. Deceleration syndrome. Traumatic aortic rupture.

Ultrasound duplex scanning of the femoral and external iliac arteries revealed that the diameter of the last 6 and 6.5 cm, which did not allow to perform known accesses

Under endotracheal anesthesia, an incision was made in the first intercostal space on the right, 12 cm long. Intercostal muscles were crossed. The first rib is resected. Parietal pleura bluntly displaced laterally. The front wall of the brachiocephalic trunk is exposed. Two purse string adventitious sutures were sequentially applied. Threads taken on the holders. Artery puncture was performed with an angiographic needle in the center of purse string sutures. A conductor is brought into the descending aorta. The needle is removed. A stent graft was placed along the conductor, positioned and disclosed in the descending aorta. In control angiography, an aortic defect was isolated. Removed delivery system and explorer. By tightening the first and second purse string sutures, hemostasis is achieved. The muscles of the anterior chest wall and skin were sutured. Aseptic dressing.

The claimed method allows stenting of the thoracic aorta in the absence of access through the femoral or external iliac arteries, for example, in the presence of small diameter arteries, metal structures in the pelvis and upper third of the thigh in patients with combined trauma and deceleration syndrome, occlusive lesions of the aorto-iliac segment , pathological tortuosity of the iliac arteries.

Claims (1)

The access method for implantation of endoprostheses into the thoracic aorta, including puncture of an artery, characterized in that a skin incision is made in the first intercostal space on the right, the muscles cross sharply, the first rib is resected, the parietal pleura is bluntly exfoliated, exposing the anterior wall of the brachiocephalic trunk, two concentric purse string the adventitious suture is punctured on the anterior wall of the brachiocephalic trunk and in the center of the purse string suture; after completion of the main stage of the operation, hemostasis of by tightening the purse string sutures.

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