RU2568535C1 - Method for plasty of main renal vessels in experiment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: closing defect with autotransplant is carried out. Cheek mucosa flap, corresponding in size to defect, is applied. Flap is sewn "edge-to-edge" by interrupted suture with vessel edge.

EFFECT: method makes it possible to reduce time for defect closing, reduce number of complications, associated with blood loss, prevent suture failure and formation of strictures.

8 dwg

Description

The invention relates to medicine, vascular surgery, can be used for plastic surgery of the great vessels in experimental animals.

A known method of plasty of blood vessels, which consists in closing the defect in the aorta or major arteries with a graft from a human umbilical cord vein, which is fixed to the defect area with a silk or synthetic suture. However, this method has the following disadvantages: it is necessary to completely isolate the vessel under extreme conditions, the presence of a canned graft, the frequent formation of aneurysms at the site of the anastomosis or the eruption of sutures with subsequent bleeding, which is fraught with hemorrhagic shock or death [1].

A known method of prosthetics of the branches of the renal artery using the internal iliac artery [2]. The technique of the operation is as follows. The vessels of the kidney cross with the preservation of the maximum possible length. Distal anastomoses of the branches of the renal artery with the branches of the internal iliac artery end-to-end with simultaneous transarterial hypothermic perfusion / T8-12C / are applied. A proximal anastomosis of the trunk of the internal iliac artery with an end-to-side aorta is performed, and the renal vein is sutured.

The disadvantages of this method are the limited use of the internal iliac artery in connection with combined lesions of the renal arteries and ileo-femoral segments, functional significance in the blood supply to the lower limb and pelvic organs, great trauma and lengthening of the operation time.

Also known is a method of renal artery plasty with a U-shaped venous graft [3]. The technique is as follows. A large saphenous vein of the femur is taken with an inflow, the renal artery is isolated, it is resected, the inverse autologous vein is anastomosed with end-to-end branches of the renal artery after the venous valves are destroyed, and the proximal anastomosis of the saphenous vein with end-to-side aorta is applied.

However, the known method has significant limitations in its implementation due to difficulties in the selection of a U-shaped graft and its suturing. In addition, the presence of venous valves that are destroyed during the preparation of an autograft for renal artery plastic surgery complicates the operation and does not guarantee complications in the postoperative period associated with insufficiently complete destruction of the valves and trauma to the intima.

The closest in technical essence is the method of plasty of the carotid artery, which consists in replacing the defect with the help of an autograft cut out of the temporal aponeurosis. However, this method has disadvantages: additional time is required for cutting the flap out of the temporal aponeurosis, complete isolation of the vessel under conditions of heavy bleeding, frequent thrombosis of the vascular structure due to the contact of platelets with the foreign surface of the graft, and scarring of the vessel [4].

A new technical result is a reduction in the closure time of the defect, a decrease in the number of complications associated with blood loss, suture failure, stricture formation, vascular thrombosis.

To achieve a new technical result in the method of plastic surgery of the main vessels, including closing the defect with an autograft, close the defect with a flap of the mucous membrane of the cheek, commensurate in size with the defect, while the flap is sutured “edge to edge” with an interrupted nodal suture with the edge of the vessel.

To confirm the implementation of the invention with the above technical result, tests were carried out on 17 outbred rabbits weighing 4,500-5,200 kg.

The operation was performed at the same time on an empty stomach. As an introductory and basic anesthesia, Zoletil 0.2 ml was used, Xylawet 0.4 ml intravenously. The experiment was performed on the abdominal aorta, namely: with an abandoned access on the left, the aorta was isolated in its lower third. A incision was made with a pointed scalpel along the anterior wall of the aorta, both transverse and longitudinal, with a diameter of 1.5 to 2 mm. A pre-prepared flap of the cheek mucosa with a size not exceeding the area of the defect in the aorta was placed on the vessel.

The flap was sutured edge to edge with a discontinuous interrupted suture, after which the blood flow was restored after 15-20 seconds. After stopping aortic bleeding and thorough hemostasis, the wound was sutured in layers tightly. In the immediate postoperative period (up to 10 days), complications were not observed. Feed began on the second day.

Animals were withdrawn from the experiment at various times after plastic surgery of blood vessels. Repeated operation was carried out under intravenous anesthesia. Zoletil 0.2 ml, Xylawet 0.4 ml. After median laparotomy, the terminal section of the abdominal aorta was resected, 8-10 mm distally and proximal from the vascular structure from the flap of the cheek mucosa. Material was taken after 1, 2, 4, 6 months from the moment of vascular plastic surgery. The resected aorta was placed in a formalin solution, followed by staining of the preparations with hematoxylin-eosin, according to van Gieson, orsein, and silver.

The results are presented in FIG. 1-8.

FIG. 1. Stained with hematoxylin and eosin. SW XI50. (2 months after surgery) In the area of an aortic wall defect, a hemmed section of the cheek mucosa with a submucosa with moderate fibrosis and weak uneven lymphocytic infiltration is determined. In the stratum of the stratified squamous non-keratinizing epithelium, hyperplasia of the cells of the basal layer is detected. Morphological signs of the inflammatory process are absent.

FIG. 2. Van Gieson stain. SW XI50. A fragment of the same area - a mature fibrous connective tissue in the submucosa of the cheek is determined, brightly colored in an intense raspberry color. In the area of surgical intervention in the vessel wall, fibrosis is also detected.

FIG. 3. Stained with hematoxylin and eosin. SW XI50. (4 months after the operation) A maturing edematous granulation tissue rich in newly formed capillary vessels with uneven, moderately expressed lymphohistiocytic and macrophage infiltration is determined in the operative intervention zone. In the lower right corner of the drug, unchanged smooth muscle elements of the muscle plate of the cheek mucosa are found.

FIG. 4. Stained with hematoxylin and eosin. SW X400. (6 months after surgery) In adventitia of the aorta, maturing granulation tissue is found with an abundance of capillaries filled with red blood cells and an edematous soft fibrous stroma with the presence of lymphohistiocytic elements, plasmocytes and single leukocytes. Signs of adipose tissue regeneration in the form of the formation of lipoblasts of various sizes are also noticeable.

Fig 5-7. SKTA was performed 5 months after surgery.

SKTA of the thoracic and abdominal aorta was performed against the background of manual injection of urographin in a dose of 4 ml with a slice thickness of up to 1.5 mm. Scan levels: from the aortic arch to the iliac arteries. Position: on the back. The rate of administration is difficult to calculate, the introduction is performed manually.

The aorta in an ascending arch with clear and even contours with a diameter of up to 8 mm is located typically. The aortic arch is up to 6 mm in diameter, the descending part of the aortic arch is up to 6 mm in diameter.

The thoracic aorta with a diameter of up to 5 mm can be traced all the way to the diaphragm, stenosis and deformation of the contours of the wall were not detected.

The abdominal aorta with a diameter of up to 5 mm can be traced throughout without signs of stenosis or aneurysmal enlargement.

The inferior vena cava contrasted well, not dilated, with a diameter of up to 4-6 mm, filling defects were not detected, the contours were even.

The study was conducted 6 months after surgery.

FIG. 8. MRA of the aorta was performed on May 29, 2013 with a bolus contrast enhancement of omniscan at a dose of 0.2 mmol / ml (1.6 ml). Three phases of the passage of a paramagnet in the 3DFFE mode with a cut-off thickness of up to 1.4 mm with interpolation are obtained. In addition, T2 VIs were obtained in a sagittal projection up to 3 mm thick. The study was performed in the supine position.

On the obtained angiograms, the descending thoracic aorta, abdominal aorta, and initial iliac arteries were visualized. The thoracic aorta with a diameter of up to 4 mm with clear and even contours without signs of defects in the lumen, stenotic or aneurysmal changes.

Clearance of the upper abdominal aorta with clear and even contours with a diameter of up to 3-4 mm; no defects of reinforcement, stenosis or aneurysmal enlargement were revealed in the lumen.

Contrast enhancement of the lumen of the thoracic and upper abdominal aorta is reduced, there is an artifact from early data collection.

Starting from the level of the anterior mesenteric artery, the contrast enhancement is satisfactory, the mouths of the renal arteries are clearly defined, their gaps with a diameter of 2-3 mm can be traced all the way to the renal sinuses on both sides. The lower abdominal aorta has minimal hemodynamically insignificant defects along the anterior and left lateral surfaces.

The iliac arteries are not changed. Thus, the advantage of the proposed method of arterial vessel plasty using a graft from the cheek mucosa flap is as follows.

1. The defect closure rate is increased.

2. A complete stop of bleeding from the affected vessel within 20-30 seconds.

3. The mucous membrane of the cheeks is a stratified squamous epithelium. It is resistant to stretching and tearing due to the large number of connective bonds and Lamina Propria and the epithelium of the mucosa. It has favorable immunological properties, resistance to infections.

6. Constant availability, ease of flap collection. With reliable fixing eliminates the deformation of the vessel.

Sources of information taken into account when compiling the description

1. RF patent No. 2099016, publ. 12/20/1997. "The method of plasty of blood vessels."

2. Kuestner L.M., Stoney R.J. The case for renal revascularization // Cardiovascular Surgery, 1995, vol. 3, N 2, p.141-154.1 A method for prosthetics of the branches of the renal artery using the internal iliac artery.

3. Novick A.C., Straffon R.A. Aortorenal Bypass with a Broached Saphenous Vein Graft for Renal Artery Disease Extending into this Branches // Surgery, 1979, vol. 85, N 2, p. 225-229. Method for renal artery plasty with a U-shaped venous graft.

4. Patent SU 935084, publ. 06/15/1982.

Claims (1)

The method of plastic surgery of the main vessels, including closing the defect with an autograft, characterized in that the defect is closed with a flap of the cheek mucosa commensurate with the size of the defect, while the flap is sutured “edge to edge” with a discontinuous interrupted suture with the edge of the vessel.

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