RU2581320C1 - Method for surgical access to iliac artery in when performing transcatheter aortic valve implantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: retroperitoneal mini-access to iliac arteries is performed through skin incision on right, from edge of costal arch along anterior axillary line towards point at 2 cm below navel, with length of 10-12 cm, lower edge of incision is ended at edge of abdominal rectus muscle. Subcutaneous fat, aponeuroses of external oblique, internal oblique and transverse muscles. Medial portion of muscle is brought inwards, transverse fascia is opened. Parietal peritoneum is stripped by swab and brought in medial direction. Terminal portion of aorta is separated and right common iliac artery. Parietal squeezed terminal portion of aorta, longitudinal cut opening lumen is implanted synthetic explant "Gore-Those" 10 cm long in proximal end of the prosthesis is set introducer 18 French. Perform transcatheter implantation of aortic valve. Method allows to perform aortal valve prosthesis in patients with small diameter of femoral arteries of less than 6.5 mm.

EFFECT: possibility of performing aortal valve prosthesis in patients with small diameter femoral arteries at impossibility to use line, transaorthal and transapical approaches.

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Description

The present invention relates to medicine, namely to cardiac surgery, and can be used to perform transcatheter aortic valve implantation.

The vast majority of surgical interventions on the aortic valve are performed for calcified aortic stenosis. For such patients, surgical aortic valve replacement is the method of choice with clearly defined indications (Bonow R., 2008) and low intraoperative mortality (Brown J., 2009). However, it should be noted that a significant portion of these patients, especially those of senile age or with severe concomitant diseases, have a high risk of surgical and postoperative complications, as well as relative or absolute contraindications to surgery in conditions of cardiopulmonary bypass (Dewey T.M., 2010 , Dimorakis I., 2011). With the introduction into clinical practice of transcatheter aortic valve replacement (or TAVI), it can be considered as an alternative to surgical treatment in patients at high risk for cardiac surgery.

Several access methods are known for transcatheter aortic valve implantation. Currently, many prefer minimal invasiveness and lightness. However, in the presence of atherosclerotic lesions of the peripheral arteries or a small diameter of the vessels, they resort to more traumatic and technically difficult approaches - transapical or transaortic. Nevertheless, in a small proportion of patients with contraindications to all the previously mentioned accesses during transcatheter aortic valve implantation, retroperitoneal mini-access to the iliac arteries can be considered as the only possible alternative solution.

The closest in technical essence to the proposed is retroperitoneal access according to C. Rob (AK Zhane. Surgical accesses to the aortic iliac vascular segment and femoral arteries. Bulletin of Surgery, 1989 No. 2, pp. 126-127). The method is as follows. A skin incision begins from the head of the XII rib to a point 1.5 cm below the navel and 2 cm going beyond it to the opposite side. The skin, subcutaneous tissue, fascia, aponeurosis of the external oblique muscle of the abdomen and the anterior wall of the vagina of the rectus abdominis are dissected in layers. After that, the more oblique and transverse muscles of the abdomen intersect in the same direction along with the transverse fascia, while the line of their cut runs perpendicular to the course of muscle fibers, blood vessels, and nerves.

The disadvantage with this access is trauma, damage to the neurovascular and muscle structures, which often leads to neuralgia, trophic disturbance and innervation of the abdominal wall. In addition, the dissection of all anatomical layers is performed at the same angle, which leads to the complexity of wound healing.

The technical result of the proposed surgical access to the iliac arteries when performing transcatheter implantation of the aortic valve is to reduce the invasiveness of the operation, better healing of the postoperative wound, expanding the indications for performing transcatheter implantation of the aortic valve when it is impossible to use other accesses.

The specified technical result is achieved by the fact that retroperitoneal mini-access is via a skin incision to the right, from the edge of the costal arch along the anterior axillary line 10-12 cm long, the lower edge of the incision is completed at the edge of the rectus abdominis muscle, dissected subcutaneous fat, aponeurosis of the external oblique , internal oblique and transverse muscles.

The main advantage of access is the limitation of intraoperative aggression with good exposure of the terminal abdominal aorta and common iliac arteries. The method allows for aortic valve replacement in patients with a femoral artery diameter of less than 6.5 mm in the absence of subclavian, transaortic and transapical approaches. The absence of dissection of the muscles and the neurovascular bundle of the anterior abdominal wall is a prevention of relaxation of the anterior abdominal wall, which makes the operation less traumatic and allows you to quickly rehabilitate patients and reduce hospitalization. The main disadvantage of access is the difficulty of its implementation in obesity.

DESCRIPTION OF THE METHOD OF TREATMENT

The patient is lying on his back. Retroperitoneal mini-access is carried out through a skin incision to the right, from the edge of the costal arch along the front axillary line towards a point 2 cm below the navel, 10-12 cm long, the lower edge of the incision is completed at the edge of the rectus abdominis muscle. Subcutaneous fat, aponeuroses of the external oblique, internal oblique and transverse muscles are dissected. The medial portion of the muscles is removed inside, the transverse fascia is opened. The parietal peritoneum is peeled off with a tuffer and retracted medially. The terminal section of the abdominal aorta and the right common iliac artery are distinguished. The aorta is squeezed out parietally, a 10 cm Gore-Tech synthetic explant is implanted, a lumen is opened with a longitudinal lumen, an 18 French introducer is installed at the proximal end of the prosthesis. Perform transcatheter aortic valve implantation. The synthetic explant is bandaged at the base, the excess is cut off, the wound on the abdomen is sutured in layers.

The method is illustrated by illustrations, where in FIG. 1 shows a diagram of retroperitoneal access to the iliac arteries and terminal abdominal aorta; a is a section diagram; b - the external and internal oblique muscles are dissected in layers, the transverse muscle is divided along the fibers, the rectus abdominis is partially crossed; c - the aorta, its bifurcation and common iliac arteries are distinguished; FIG. 2 - an 18 French sheath introducer is installed in the proximal end of the right common iliac artery.

Example No. 1

Patient A., 77 years old, was admitted to the Department of Cardiac Surgery of the State Budgetary Healthcare Institution “Scientific and Practical Center of Cardioangiology” DZM with complaints of shortness of breath with moderate physical exertion. In the spring of 2014, severe aortic stenosis was first diagnosed. During auscultation of the heart, a gross systolic murmur was revealed with a maximum on the aorta and conducting to the carotid arteries.

Echocardiography: expansion of the left atrium. Satisfactory contractility, ejection fraction = 75%. KDR = 4.3 cm, KSR = 2.4 cm, BWW = 83 cubic meters. cm, KSO = 20 cubic meters cm The thickness of the interventricular septum in the diastole is 13 mm, the thickness of the posterior wall in the diastole is 13 mm. The aorta is sclerosed, calcification of the valves of the AK. When D-echo: regurgitation in the left ventricle 2 degrees, the velocity of the systolic flow at the mouth of the AO = 4.8 m / s, the maximum gradient = 92 mm RT. Art., average = 55 mm RT. Art., the estimated hole area AK = 0.54 cm ² . Mitral valve: the movement of the valves in different directions, with D-echo: average diastolic gradient = 0.9 mm RT. Art., regurgitation in drugs 1-2 degrees. Tricuspid valve: the movement of the valves is multidirectional, with D-echo regurgitation in PP 0-1 degrees, SDLA = 37 mm RT. Art.

MSCT of the aorta and arteries of the lower extremities with contrast: atherosclerotic lesion of the abdominal and thoracic aorta, total calcification of the aortic valve. The right subclavian artery is 6.2 mm in diameter; in the proximal segment it has a C-shaped fixed bend. In the wall of the arch and the descending aorta are calcified inclusions. Common iliac arteries with a diameter of 7.4 × 8.3 mm on the right, 7.0 × 7.3 mm on the left, external iliac arteries on the right 6.3 × 7.1 mm, on the left 5.3 × 5.5 mm, superficial femoral arteries - on the right 6.8 × 6.9 mm, on the left - 6.2 × 6.6 mm.

ECG: sinus rhythm, correct. Heart rate = 72 beats. in minutes Signs of left ventricular myocardial hypertrophy.

On the basis of the examination, the diagnosis was made: PPS. Pronounced calcified aortic stenosis. NK 1 tbsp. NYHA 2 FC Hypertension 2 tbsp.

On October 27, 2014, the patient underwent transcatheter aortic valve implantation with retroperitoneal mini-access through the iliac arteries.

Retrograde catheterization of the aorta and antegrade catheterization of the inferior vena cava with left transfemoral access were performed under local anesthesia, 7Fr and 6Fr introducers were installed, respectively. An electrode for a temporary EX is inserted into the cavity of the right ventricle. Access to the right common iliac artery and terminal aorta was performed, for which retroperitoneal mini-access was used by dissecting the skin, subcutaneous fat, aponeuroses of the external oblique, internal oblique and transverse muscles on the right. An oblique skin incision was made from the edge of the costal arch along the anterior axillary line towards a point 2 cm below the navel to the edge of the rectus abdominis muscle, the length of the incision was 10-12 cm. The medial portion of the muscles was taken to the side, the transverse fascia was opened, the parietal peritoneum was peeled off with a tuffer and allotted medially. The terminal aorta and the right common iliac artery were isolated. The terminal section of the aorta was squeezed out, a Gore-Tech synthetic explant was implanted 8 mm long, the jaw length was 10 cm. An 18 Fr introducer was installed at the proximal end of the prosthesis, which was fixed with Dacron thread on two levels. Two Pigtail 5 Fr catheters were inserted through the introducers on the guides and inserted into the aorta (non-coronary sinus) and left ventricle. A direct measurement of the pressure gradient between the aorta and the left ventricle was performed. A balloon catheter was brought into the projection of the aortic valve along the conductor. We performed balloon dilatation of the aortic valve with ECS at a frequency of 180 cpm. The balloon catheter was removed. An aortic valve was inserted through a rigid conductor on the delivery device, and the delivery system was positioned in the implantation zone. Aortography of the aortic root was performed, then the aortic valve was implanted. The delivery device is removed. The prosthesis in the common iliac artery was bandaged at the base, the excess was cut off. The wound was sutured in layers tightly leaving active drainage in it. A cosmetic intradermal suture was applied. Drainage was removed after 1 day.

During the operation, technical difficulties with the allocation of the iliac arteries and the terminal aorta did not arise. After the operation, the patient was in the intensive care and anesthesiology department for 24 hours, then transferred to the cardiac surgery department. The postoperative period without complications, the postoperative wound without features. The patient was discharged from the hospital on the 7th day after the operation to the rehabilitation center. As a result of the operation, regression of dyspnea, improvement of well-being, increase of tolerance to physical activity are noted.

According to echocardiography, a positive dynamics of the pressure indicators on the aortic valve was revealed. Maximum gradient = 17 mmHg. Art., average = 10 mm RT. Art., the estimated hole area AK = 1.9 cm ² .

The proposed method of retroperitoneal mini-access to the iliac arteries during transcatheter aortic valve implantation was applied to 6 patients with a femoral artery diameter of less than 6.5 mm. All patients were diagnosed with severe aortic stenosis and there was no possibility of transcatheter aortic valve implantation via subclavian, transaortic and transapical access.

All patients had a smooth course of the postoperative period, no complications were noted. The postoperative wound healed by primary intention. There was a significant decrease in the maximum systolic and average gradient on the aortic valve according to echocardiography.

Thus, on the basis of the studies, the feasibility of using retroperitoneal mini-access to the iliac arteries is scientifically substantiated, this method allows you to expand the indications for transcatheter implantation of the aortic valve, helps to quickly rehabilitate patients, reduce hospitalization, reduce the morbidity of the operation, and better heal the postoperative wound.

Claims (1)

The method of operative access to the iliac arteries when performing transcatheter implantation of the aortic valve using retroperitoneal mini-access to the terminal abdominal aorta, characterized in that retroperitoneal mini-access is performed through a skin incision to the right of the costal arch along the front axillary line towards a point on 2 cm below the umbilicus 10-12 cm long, the lower edge of the incision ends at the edge of the rectus abdominis muscle, subcutaneous fat and aponeuroses of the external oblique are dissected of the oblique and transverse muscles, the medial portion of the muscles is removed inside, the transverse fascia is opened, the parietal peritoneum is exfoliated with a tuffer and medially removed, the terminal section of the abdominal aorta and the right common iliac artery are separated, the terminal section of the aorta is parietally squeezed, a Gore-Tech synthetic explant is implanted 10 cm, 18 French sheath is inserted into the proximal end of the prosthesis, fixed with Dacron thread on two levels, transcatheter aortic valve implantation is performed, synthetic explant erevyazyvayut at the base, the excess is cut off, the wound is sutured in layers on the abdomen.

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