RU2685688C1 - Method of open surgical reconstruction of venous valve - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to microvascular surgery. After the transverse incision of the wall of the common femoral vein, the proximal part of the vein is gradually turned inside with the endophlebectomy, wherein not only connective tissue septa, but also excessive neointima are excised. Then, flaps performing the functions of a neo-valve are formed from the vein proper wall by two or three fixing sutures.EFFECT: method enables decreasing axial reflux.1 cl, 6 dwg

Description

The invention relates to medicine, namely to microvascular surgery and can be applied in the practice of microsurgical treatment of post-thrombotic disease (PTB).

The main indication for the reconstruction of the valves of the veins is pronounced pathological reflux in the deep main veins, complicated by a distinct insufficiency of the function of the musculo-venous pump, which cannot be corrected by phlebectomy and ligation of perforating veins.

The known method of direct valvuloplasty by Kistner [Kistner R., 1968]. The segment of the main vein with the valve to be reconstructed is isolated through a longitudinal incision. By donating blood in the retrograde direction, they clarify the diagnosis of valve insufficiency. The patient is intravenously injected with 5000 IU of heparin. Atraumatic vascular clamps are applied to the vein. Venotomy performed in the longitudinal direction at the level of the valve through the commissure, so as not to damage the leaf.

Excessively stretched valves are strengthened with seams by a thin thread of prolene by tightening the free edge of the valves at the point where the commissure is located, which in such cases is usually stretched. Form a new commissure. To eliminate valve prolapse and restore its closure function, the excess part of the stretched edge of the valve is sutured and the venotomic opening is sutured.

However, the true clinical significance of the operation is difficult to assess, since the intervention on the valve is accompanied by phlebectomy and perforating vein ligation, and isolated straight valvuloplasty is rarely performed.

The known method of microsurgical reconstruction of an insolvent venous valve (R. Kistner. "Surgical archive", t. 110, pp. 1336-1342. Surgical recovery of an insolvent valve of the femoral vein. November 1975). According to Kistner's operation, the femoral veins are separated by a cut in the upper third of the thigh and a valve is found, usually located at the mouth of the femoral vein. After clamping, the blood is displaced proximally. When renewing the possibility of retrograde current, an insolvent valve allows blood to flow into the subvalvular vein segment. When restoring an insolvent valve, a clamp is placed and the vein is cut longitudinally 3 cm below the valve in the proximal direction through the commissure of the cusps and the incision is continued further by 3 cm, warning about the possibility of damage to the cusp during dissection in the area of the commissure. An overstretched, lowered valve leaflet is found, allowing backflow of blood. Restoration is done by stitching an excess leaflet to the vein wall at the attachment point to the vein wall with 4-6 interrupted sutures. a distance of 2 mm from the edge of the mount, then the needle with the thread through the puncture from the inside out. The knots are tied on the outer wall of the vein. Similarly, reduce the sash by dissected commissure. The question of the degree of reduction of the sash is considered debated. Phlebotomy is sutured with interrupted sutures, warning of the possibility of deformation of the valves. After phlebotomy closure, check valve competence. If the valve is inconsistent, the operation is repeated or ligated vein (US Pat. RU №2193355, IPC AV 17/00, 2001).

The disadvantage of this method is unreasonably large incision of the vein. Dissection of the vein through the commissure dangerously accidental, but likely damage to the valves. A significant incision of the vein lengthens the operation, holding it through the lower hemisphere of the valve leads to its deformation during the suturing of the incision. The method does not provide for the restoration of disturbed relationships of the valve structures in the dilated vein. No measures are taken against its further dilation. In addition, it does not eliminate the possibility of further dilatation of the venous wall of the valve as a result of the varicose process, resulting in a distal position of the neocomissories with the lowering of the leaflets, leading to a recurrence of valvular insolvency. The possibility of the eruption of the seams of the venous wall in the area of neocomissures is also not excluded, which leads to a recurrence of valve failure.

The known method of microsurgical reconstruction of insolvent venous valves (Patent RU 2193355, publ. 27.11.2002, Bull. No. 33) Perform a longitudinal dissection of the vein in the valve sine in the middle between the commissures. Measure the length of the free edge of the valves. Lay on the free edge of the valves half the difference between the length of the free edge of the valve and the length of the semicircle of the vein. Pick up the free edge of the sash at a distance of the length of the excess of the free edge set aside from the commissure by puncture from the outside inwards with an atraumatic needle. Remove the thread from the lumen of the vein through a puncture from the inside to the outside. Similarly, they create a second neo-commissure from the other side. Impose intraparietal circular purse-string sutures in adventitia without narrowing of the lumen of the vein in the over-valve and sub-valve segments. During the formation of neocomissures, threads are left that impose longitudinal intragranular sutures in adventitia in the proximal direction from neocomissures with fixation to the upper circular pouch suture.

The known method of intravasal correction of chronic venous insufficiency by implantation of artificial venous valves (application number 2003117256, filing date 10.12.2004). The method allows to eliminate the valve venous insufficiency by implanting an artificial valve of polytetrafluoroethylene, and the artificial valve is not a mono-gate, formed from two triangular flaps, but a valve, which is a cylinder equal in diameter to the vein into which it is implanted, while the implantation of the main vein completely intersects, the proximal part of the valve along the vein is held in the cranial direction and fixed there two diametrically against positive seams - taped, the distal portion of the valve is fixed in the anastomosis when stitching a crossed vein. The disadvantage of this method is the use of artificial materials, which leads to a high frequency of thrombosis in the area of the formed valve.

The closest analogue to the claimed invention is a method of intravasal plasticity of the venous valve in chronic venous insufficiency of the lower extremities (Patent RU No. 2582211, publ. 04/20/2016 Byul. No. 11), according to which complete intersection of the main vein is performed, after which a valve is formed from its own vein , for which the vein intersects, and the adductor end is held in the abductor due to mobilization of the vein for 5-8 cm. Pick up the opposite free edges of the adductor end of the vein by puncture from the inside to the outside. traumatic needle 5/0. Then, at a distance of half the diameter of the vein, the future valve leaves are fixed at the outlet end of the vein, leading to the latter in the cranial direction leading the end of the vein. Impose circular purse stitches without narrowing the lumen of the vein, fixing the discharge edge to the resulting. The method eliminates the need to use artificial materials and reduce the number of thrombosis in the field of venous valve reconstruction, however, the disadvantage of this method is the preservation of axial reflux, which in some cases leads to the resumption of symptoms of postthrombotic disease (PTB).

The objective of the present invention was to achieve a reduction in axial reflux due to a change in the geometric shape of the neo-valve and the technique of its formation from its own vein wall.

The author has developed an original method for the formation of a venous neo-valve from one's own vein by screwing the walls of the latter into its lumen, as shown in FIG. 1 and FIG. 2, and fixing them in a new position.

The proposed method is characterized by the following sequence of actions: after transverse dissection of the wall of the common femoral vein, the proximal part of it is gradually screwed inwardly to perform endoflebectomy, and not only the connective tissue septa are excised, but also excessive neointima is formed, then two or three fixation swiveling sutures are cut out of the right vein that perform the functions of a neocaval (Fig. 3 and Fig. 4).

In experiments on vein preparations, the required and proper thickness of the vein wall acting as a valve (Fig. 5), the optimal surgical technique for forming the valve roller and the need for extravasal support of the formed neo-valve were determined.

In the course of numerous experiments using the methods of mathematical modeling (Fig. 6), the optimal parameters of the neocaval were determined, its effective closing function, the absence of obstruction to the venous outflow, the reduction of axial reflux were convincingly proved.

Claims (1)

The method of open surgical reconstruction of the venous valve, characterized in that after a transverse dissection of the wall of the common femoral vein, the proximal part of it is screwed inward to perform endoflebectomy, while not only the connective septa are excised, but also excess neointima, after which the fixing screw is sewn from the own wall of the vein seams form the valves that perform the functions neokvalan.

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