RU2635486C1 - Method for retrograde catheterization of mesenteric artery-arcade in case of acute mesenterial ischemia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: infusion catheter is retrogradely introduced to the distal artery-arcade section that supplies the intact intestinal region and is directed proximally till bifurcation with the artery-arcade that supplies the ischemic area of the intestine. The artery-arcade in the area of catheter insertion is then bandaged on the catheter for compensatory amplification of the volumetric blood flow velocity in the ischemic intestine. The catheter is withdrawn to the anterior abdominal wall, fixed, the laparotomic wound is closed, and the infusion of solutions of spasmolytic and anticoagulant drugs is carried out along the installed catheter according to the traditional therapeutic scheme.

EFFECT: method allows to improve the blood supply to the intestinal wall in case of acute impairment of blood circulation in the superior mesenteric artery by regional intraarterial infusion and simultaneously increase the volumetric velocity of blood flow in the arteries that supply blood to the ischemic areas of the intestine.

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Description

The invention relates to medicine, namely to surgical correction of local arterial blood flow in acute ischemic damage to the intestine, and can be used in emergency abdominal surgery and angiosurgery.

Acute violation of mesenteric circulation is a pathological condition that develops with atherosclerotic mesenteric thrombosis, thromboembolism of mesenteric arteries, strangulated intestinal obstruction, and trauma to the vessels of the mesentery of the small intestine. Mortality in these conditions reaches 60-90% and does not have a significant tendency to decrease (1, 2).

The main cause of death in patients with acute ischemic damage to the intestine is the development of acute arterial insufficiency in the pool of the affected vessel, the formation of heart attack and necrosis of the intestinal wall, complicated by peritonitis and multiple organ failure.

One of the effective methods for the correction of acute arterial insufficiency in the pool of thrombosed vessels is thrombembolectomy. Removal of a thrombus from the mesenteric artery lumen is accompanied by the restoration of regional blood flow and is a fundamental condition for maintaining the viability of parabiotically altered intestinal wall tissues (3, 4).

However, the effectiveness of this operation depends on the location of the thrombus (embolus) and is determined by the features of the anatomical structure of the branches of the superior mesenteric artery, which is usually divided into three segments: I segment from the mouth of the artery to the site of discharge a. colica media, segment II - between the discharge zones a. colica media and a. ileocolica, segment III - distal to discharge a. ileocolica. Thrombembolectomy is most effective in the localization of a thrombus in segments I and II and is inappropriate when thrombosis spreads to the third segment of the superior mesenteric artery (1). Due to the peculiarities of the anatomy of the vascular bed in this (third) segment, the small diameter of the artery, attempts at intravascular intervention in the III segment of the mesenteric artery are counterproductive. In addition, thrombectomy in segments II and III of the superior mesenteric artery (if it was made later than 3 hours from the onset of the disease) is accompanied by the development of reperfusion syndrome, in which the picture of damage to the small intestine is much more severe than with “pure ischemia” without restoration of blood flow (5).

One of the producing factors of damage to the mucous membrane of the intestinal wall in this case is a decrease in total blood pressure and, as a consequence, a decrease in perfusion pressure in the intestinal mucosa (1). In patients after thrombectomy (lesions in the I-II segments of the superior mesenteric artery), and in patients for whom thrombectomy is not indicated (lesions in the III segment of the superior mesenteric artery), it is advisable to carry out regional intravascular therapy aimed at maintaining perfusion of the intestinal wall (1 )

Closest to the claimed solution is the traditional method of intra-arterial catheterization and infusion using the Seldinger method, in which the artery or aorta is catheterized and the intra-arterial infusion of anticoagulant and antispasmodic drugs (5, 6). The method allows you to enter drugs directly into the arterial trunk supplying the damaged area, which provides a relatively high regional concentration of pharmaceuticals in the damage zone (7, 8). A catheter into the abdominal aorta is inserted through the peripheral artery (most often through the femoral), under X-ray control it is brought to the mouth of the mesenteric artery, after which it is antegrade introduced into its mouth and a regional infusion of the drug solution is performed (9, 10).

This method, despite the prevalence in clinical practice, has a number of significant drawbacks and limitations in use in acute circulatory disorders in the mesenteric arteries:

1. It is difficult to bring the catheter directly to the site of the damaged intestine through the vessels of the III segment of the mesenteric artery, as a result of which the solution is infused through the mesenteric artery trunk at the level of its mouth and initial section, which leads to an unprincipled uniform distribution of the drug substance through the bloodstream of the entire mesenteric pool. Moreover, the effective concentration of the drug is least in the area with a relatively low blood flow, that is, in the area of ischemic damage to the intestine;

2. Due to the antegrade direction of catheter insertion (from large arterial vessels to small vessels), the progressive movement of the catheter into increasingly smaller mesenteric arteries is accompanied by an increase in the proportion of the artery section blocked by the catheter and, as a result, a decrease in the volumetric blood flow velocity in the damaged area.

Thus, the antegrade introduction of the catheter by the Seldinger method implies a relatively low concentration of the drug in the damaged intestine during catheterization through the mouth of the superior mesenteric artery, and a relative increase in the regional concentration of drugs by catheter into the distal arteries is accompanied by a decrease in the volumetric blood flow velocity in the ischemic zone due to overlap of the lumen of the artery with a catheter.

The technical problem solved by the invention is the creation of a method for retrograde catheterization of the mesenteric artery arcade in acute mesenteric ischemia, which allows the catheter to be brought directly to the site of the damaged intestine, to increase the regional concentration of drugs and, at the same time, the volumetric blood flow in the arteries supplying the ischemic sections of the intestine.

The technical result from the use of the invention is to improve blood supply to the intestinal wall in case of acute circulatory disturbance in the superior mesenteric artery by regional intra-arterial infusion at the level of segment III of the artery and at the same time increase the volumetric flow rate in the arteries supplying ischemic bowel sections.

This result is achieved by the fact that in the method of retrograde catheterization of the mesenteric artery arcade in acute mesenteric ischemia, which involves the introduction of a catheter into the arcade artery supplying the ischemic section of the intestine for regional intra-arterial infusion, the arterial catheter is inserted into the arterial retrograde artery blood supplying the intact section of the intestine, and is carried out in the proximal direction until bifurcation with the artery-arcade, blood supplying the ischemic section of the intestine, and the artery arcade in the area of catheter insertion is ligated on the catheter to compensate for the increase in the volumetric blood flow velocity in the ischemic intestine.

The invention is illustrated by drawings, which show:

in FIG. 1 is a diagram of a mesentery with vessels, with a thrombosed mesenteric artery and a section of the ischemic intestine;

in FIG. 2 - scheme of retrograde regional catheterization of the mesenteric artery-arcade in acute mesenteric ischemia;

in FIG. 3 is a photo of a site of ischemic gut with a catheterized artery-arcade;

in FIG. 4 is a photo of the process of optical coherence tomography of the ischemic colon;

in FIG. 5 - the result of optical coherence tomography of the ischemic gut - optical microangiograms: a - before catheterization of the artery-arcade and intra-arterial infusion, b - after catheterization of the artery-arcade and regional intra-arterial infusion.

The diagrams show: 1 - zone of ischemia in the small intestine; 2 - trunk a, closest to the zone of intestinal ischemia. jejunales before dividing into ascending and descending arcades; 3 - branch of artery a. jejunales, after bifurcation departing towards the ischemic site; 4 - branch of artery a. jejunales, after bifurcation departing towards a healthy, non-limiting section of the intestine; 5 - intact a. jejunales; 6 - catheter in the lumen of an artery arcade; 7 - ligature on an artery arcade with a catheter; 8 - the trunk a closest to the area of intestinal ischemia. jejunales; 9 - cannula needle in the lumen of an artery arcade; 10 - sensor optical coherent tomograph; 11 - signs of improved blood supply to the intestinal wall according to optical coherence tomography - newly appeared functioning microvessels.

Hereinafter, the arteries supplying the small intestine are indicated as follows (Fig. 1):

1) the closest trunk to the zone of intestinal ischemia (1 in Fig. 1) is a. jejunales before dividing into ascending and descending arcades - "a. jejunales "(2 in Fig. 1);

2) branch of the artery a. jejunales, after bifurcation departing towards the ischemic site - "arcade-1" (3 in Fig. 1);

3) branch of the artery a. jejunales, after bifurcation departing towards a healthy, non-limiting section of the intestine - "arcade-2" (4 in Fig. 1).

A catheter is inserted retrograde into the proximal portion of Arcade-2 (6 in FIG. 2). Moreover, “arcade-2” is bandaged on the catheter inserted into it (7 in Fig. 2), which leads to a compensatory redistribution of blood flow in favor of “arcade-1”, increasing the volumetric blood flow velocity in the latter. A distal section of the inserted catheter during catheterization is carried out to the arcade bifurcation zone, which allows the infusion medium to be introduced directly into the ischemic zone. In this case, blood supply to the intact section of the intestine is carried out from intact a. jejunales (5 in Fig. 2).

A regional infusion catheter is retrogradely inserted into the distal portion of the arcade artery supplying the intact portion of the intestine and proximal until bifurcation with the arcade supplying the ischemic portion of the intestine, while the arcade artery is ligated on the inserted catheter for compensatory volume blood flow in the ischemic colon. The catheter is brought to the anterior abdominal wall, fixed, the laparotomy wound is closed, and the catheter is installed to infuse solutions of antispasmodic and anticoagulant drugs (e.g., papaverine and heparin solutions) according to the traditional therapeutic scheme (10).

The method is as follows. After a laparotomy, in a patient with acute mesenteric ischemia or in a laboratory animal with a model of acute mesenteric ischemia, the intestine is inspected and the area of ischemic damage is determined. Find the pulsating closest to the site of damage a. jejunales and the departing arcade-1 and arcade-2. The peritoneum in the projection of the proximal arcade-2 "is opened, the artery is retrogradely catheterized by introducing a catheter, for example Introcan-W (B | BRAUN, Germany). With a minimum diameter of the catheterizable artery, it is possible to use an insulin syringe needle of 29 G (0.33 × 13 mm) (Fig. 3). Artery puncture by cannula or syringe needle is carried out 1 cm distal to the bifurcation, after which it is introduced retrograde to the bifurcation of the arcades. After that, the catheterized Arcade-2 is ligated on the catheter, which simultaneously fixes the catheter and stops the blood discharge through the catheterized Arcade-2, redistributing it in favor of Arcade-1, which supplies the site of the ischemic gut (Fig. 2). Hemodynamics in the area supplied by the bandaged Arcade-2 are compensated by collateral circulation through the arcade arteries of the intact part of the intestine (5 in Fig. 2). Then the peritoneal wound is sutured, the catheter is brought to the anterior abdominal wall, fixed, the laparotomy wound is closed, and 2% Papaverine solution is infused according to the method of G. Simonetti, 1992 according to the installed catheter.

A series of experimental preclinical trials of the method on 3 rabbits. In all animals, acute mesenteric ischemia was modeled by ligation of the cranial mesenteric artery at the level of its III segment (Fig. 3). A catheter for infusion was retrogradely inserted into the distal portion of the artery-arcade supplying the intact intestine, and carried out in the proximal direction until bifurcation with the arcade-supplying blood supply to the ischemic portion of the intestine, and the artery-arcade in the area of catheter insertion was ligated on the catheter. After artery ligation, the dynamics of blood circulation in the wall of the small intestine was recorded in the area that was supplied with blood by the ligated artery. The functional state of the hemocirculatory bed was evaluated using the technology of optical coherent therapy (OCT), based on interferometric detection of backscattered light in the infrared range. This technology makes it possible to visualize the microvascular network in three-dimensional angiography and in vivo to monitor blood movement in the microvascular bed in real time. The physical principle of isolating the vascular network is based on determining the temporal variability of the amplitude and phase of the OCT signal in a series of pixelated OCT images of the same tissue region: in those places where the signal rapidly changes from scan to scan, there is flowing fluid (blood); where the amplitudes and phases of the image pixels are stable, there is no fluid movement (11). According to OCT, the presence of functioning arterial vessels and the severity of the vascular network in the intestinal wall were evaluated before and after catheterization of the arcade artery supplying the ischemic section of the intestine (Fig. 4). Artery arc catheterization was performed using an Introcan-W intravascular cannula 0.6 × 19 mm (B | BRAUN, Germany), the cannula was performed retrogradely as described. After catheterization of the artery arcade, an intra-arterial infusion of a 2% Papaverine solution was carried out according to the method of G. Simonetti, 1992. The effectiveness of the intra-arterial infusion was evaluated using OCT. In all three experiments, a significant change in the picture of the functional state of the microvasculature was achieved: after catheterization and intra-arterial infusion, functioning arterial vessels appeared on OCT-grams of the ischemic section of the intestine, their diameter increased, and the density of the capillary network increased (Fig. 5).

Thus, the proposed method for retrograde catheterization of the mesenteric artery-arcade in acute mesenteric ischemia is new, effective and safe. It allows to improve the results of regional intra-arterial infusion by regional injection of drug solutions into the artery as close as possible to the area of ischemic tissue damage, preventing a decrease in the volumetric rate of regional blood flow due to a compensatory increase in the volumetric velocity of the blood flow through the artery-artery.

Information sources

1. Bagdasarov V.V. Draft protocol (clinical recommendations) for the diagnosis and treatment of acute intestinal ischemia [Electronic resource] / V.V. Bagdasarov, E.A. Bagdasarova, A.A. Atayan. - Moscow. - 2014. - Access mode: http: // community- surgeons.rf/stranica-pravlenija/klinicheskie-rekomendaci/urgentnaja-abdominalnaja-hirurgija/klinicheskie-rekomendaci-po-diagnostike-i-lecheniyu-ostroi-intestinalnomlis .

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Claims (1)

The method of retrograde catheterization of the mesenteric artery-arcade in acute mesenteric ischemia, which consists in introducing a catheter into the arcade artery supplying the ischemic section of the intestine for regional intra-arterial infusion, characterized in that the catheter for infusion is inserted retrogradely into the distal arterial artery-artery section of the intestine, and is carried out in the proximal direction until bifurcation with the artery-arcade supplying the ischemic section of the intestine, and the artery-arcade in the region In this case, the catheter insertion is ligated on the catheter to compensate for the increase in the volumetric blood flow velocity in the ischemic intestine.

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