RU2704215C1 - Method for surgical management of aneurisms of native vascular access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to vascular surgery. Skin incision is made along an aneurismically changed area of the arteriovenous fistula. Arteries and vein anastomosis, an aneurismically changed vein is separated to an intact segment. Anastomosis point is applied. Discharge of arteriovenous anastomosis and aneurism is performed. Autoprothesis is formed using internal and external templates. Venous thrombosis is performed. Vessel is laid in a bed, with formation of an anastomosis between an artery and a vein. Newly formed autoprosthesis with a vein thickness of up to 2 mm is reinforced with an external thin-wall exoprosthesis with diameter of 10 mm, with a thickness of the perforated wall of up to 0.02 mm. Second version includes a skin incision along an aneurismically changed area of an arteriovenous fistula. Artery and vein anastomosis and an aneurismically changed vein are separated to an intact segment. Anastomosis point is applied. Discharge of arteriovenous anastomosis and separation of aneurismically changed vein are performed. Veins are formed using internal and external templates. Veinotomy is performed and the vessel is placed in the bed. Anastomosis is formed between the artery and vein. Newly formed autoprosthesis with a thick vein aneurism with a vein thickness of more than 2 mm is reinforced with an external thin-wall exoprosthesis with diameter of 12 mm, with thickness of the perforated wall of up to 0.02 mm.

EFFECT: method enables preventing postoperative complications provided that puncture and catheterization is improved during hemodialysis.

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Description

The invention relates to medicine, specifically to vascular surgery, and can be used in the surgical treatment of aneurysms of native vascular access.

Vascular access allows for chronic dialysis, providing medical personnel access to the patient’s circulatory system. For the patient, a problem with access usually leads to impaired access function and inadequate hemodialysis, hospitalization, and even premature death. In case of loss of access, it is necessary to restore it, or to form a new access, which is possible only when performing a surgical operation, followed by a postoperative recovery period. The habitual life of the patient is broken, its quality is reduced.

On the human body there are about 10 places suitable for creating vascular access. With each subsequent surgery, future choices are limited. Numerous fistula punctures in the same place, after some time, leads to the formation of aneurysm. Aneurysmal expansion of the native arteriovenous fistula is a late complication of vascular access and, according to the latest literature, the frequency of their appearance varies from 5% to 60%. [1,2]. Template puncture leads to weakness of the muscular wall of the fistula and aneurysmal transformation of the fistula. Over time, the blood flow in the initially normal fistula continues to increase, which leads to the expansion of the fistula vein. Aneurysm is more often formed “upstream” of the blood stream, retrograde from venous stenosis, especially in places of repeated punctures. It should be noted that such aneurysms have an increased risk of thrombosis of massive external bleeding. Indications for surgical correction, as well as the type of intervention, are currently controversial.

The aim of the proposed invention is the creation of a surgical method for the treatment of aneurysms of arteriovenous fistulas using an exoprosthesis.

The method described in the article Reinforced Aneurysmorrhaphy for True Aneurismal Hemodialysis Vascular Access, S. Rokosny, P. Balaz, P. Wohlfahrt, D. Palous, L. Janousek, 2014 [3], which describes the method of surgical treatment, was adopted as a prototype. aneurysms of native vascular access. Method of operation: the first skin incision (3-5 cm) is performed at the site of the anastomosis, the rest along the entire length of the aneurysmally altered vein. Anastomosis of arteries and veins is isolated, as well as the entire aneurysmally altered vein to the intact site. A clamp is applied to the site of the anastomosis, the arteriovenous anastomosis is disconnected, the aneurysmal vein is excised throughout. In the future, to excise excess tissue and suturing a vein, use a special BalRok clamp. For the formation of a cylindrical autoprosthesis from an aneurysmal vein, cylindrical internal BalRok clamp templates with a diameter of 5, 6 or 7 mm are used. The selected template is placed inside the aneurysmically dilated vein, the outside of the vein is pressed with the outside of the BalRok clamp, the excess part of the vein is fixed with the clamp, and dissected longitudinally with a scalpel. Next, the vein is sutured longitudinally by a continuous vascular suture, forming a cylindrical autoprosthesis with a selected inner diameter size. Outside, the prosthesis is reinforced with a Pro Vena braided exoprosthesis, and its diameter is 1 mm greater than the diameter of the internal template. The vessel is laid in its original place, anastomosis is again formed between the artery and vein. The wound is actively drained.

The disadvantages of the method.

1. The technique of using the BalRok clamp excludes the possibility of open thrombendarterectomy, thereby eliminating the possibility of surgery on vascular access aneurysms complicated by thrombosis;

2. Due to the tortuosity of the course and the large size of the bed of the extracted aneurysm of the arteriovenous fistula, laying in the old bed leads to difficulties in hemodialysis and complications: a) the skin suture, and later the scar, is located above the autoprosthesis, this makes it difficult to puncture during hemodialysis; b) since the bed of the extracted aneurysm exceeds the size of the reconstructed vein, this leads to the formation of a hematoma around the vein and, in turn, can lead to infection of the resulting hematoma, and in the future - the exoprosthesis;

3. Suturing of the vein along the anterior wall may lead to the inability to catheterize the vein for hemodialysis;

4. The use of the Pro Vena exoprosthesis, the maximum diameter of which is 8 mm, limits the application of this method to the correction of extremely thin-walled aneurysms with a maximum wall thickness of up to 1 mm, the authors use veins with a thickness of 0.5 mm. (Recommended inner fistula clearance 6 mm + 1 mm front wall + 1 mm back wall = 8 mm).

The invention consists in a combination of essential features sufficient to achieve the desired technical result, consisting in the possibility of treating both thin-walled, uncomplicated aneurysms of arteriovenous fistulas and thick-walled, complicated by thrombosis, a method that prevents postoperative complications, provided that the possibility of puncture and catheterization is improved during hemodialysis.

The essence of the invention lies in the fact that the method of surgical treatment of aneurysms of native vascular access includes a skin incision along the aneurysmically altered section of the arteriovenous fistula, the allocation of the anastomosis of the artery and vein, the aneurysmically altered vein to the intact section, the clamping of the anastomosis, the dissociation of the arteriovenous anastomosis, and excision of the aneurysm, the formation of an autoprosthesis using internal and external templates, venotomy, the laying of a vessel in a bed, with the formation of an anastomosis between ar teria and vein. A newly formed autoprosthesis with a thin-walled aneurysm, with a vein thickness up to 2 mm, is reinforced with an external thin-walled exoprosthesis with a diameter of 10 mm, with a perforated wall thickness of up to 0.02 mm.

A method for surgical treatment of aneurysms of native vascular access includes a skin incision along the aneurysmically altered section of the arteriovenous fistula, isolation of the anastomosis of the artery and vein and the aneurysmically altered vein to the intact region, clamping on the site of the anastomosis, dissociation of the arteriovenous anastomosis and separation of the aneurysmically altered vein, and external templates, venotomy, laying the vessel in the bed, with the formation of an anastomosis between the artery and vein. A newly formed autoprosthesis with a thick-walled aneurysm, with a vein thickness of more than 2 mm, is reinforced with an external thin-walled exoprosthesis with a diameter of 12 mm, with a perforated wall thickness of up to 0.02 mm.

A venotomy is performed along the back wall of the vessel, aneurysmal vein is excised using an internal template with a diameter of 6 mm, the formed reinforced prosthesis is placed in a new bed in a straight line, to a depth of 3 mm from the skin surface, an anastomosis is formed between the artery and vein.

Performing a venotomy on the posterior wall of the vessel allows you to place the intact surface of the vein in the puncture zone, which reduces the likelihood of complications, facilitates puncture during hemodialysis. As a result, a thicker section of the reconstructed vein will be outside the punctured area. This reduces the risk of injury to the vascular suture of the reconstructed vein during punctures for a hemodialysis session, due to the location of the unchanged wall on the front surface, which makes punctures more comfortable.

Cleaning the lumen of the aneurysm from thrombotic masses allows you to partially, or completely, restore the function of the lost fistula.

Excision of the aneurysmal vein using an internal template with a diameter of 6 mm is carried out to more accurately form the lumen of the vein, since the "gold standard" of the internal lumen of the arteriovenous fistula is precisely the diameter of 6 mm.

Reinforcing a newly formed autoprosthesis with a thin-walled aneurysm, with a vein thickness up to 2 mm, an external thin-walled exoprosthesis with a perforated wall up to 0.02 mm thick, a diameter of 10 mm, and with a thick-walled aneurysm, with a vein thickness of more than 2 mm, an external thin-walled exoprosthesis 12 mm allows strengthen the vein skeleton and prevent the re-formation of aneurysm. Since the recommended internal lumen of the fistula with a thin-walled aneurysm: 6 mm + 2 mm anterior wall + 2 mm posterior wall = 10 mm - diameter of the exoprosthesis; with a thick-walled aneurysm with a vein thickness of more than 2 mm, the recommended internal lumen of the fistula is 6 mm + 3 mm front wall + 3 mm posterior wall = 12 mm.

The method is illustrated in the illustrations below, where:

In FIG. 1 - shows aneurysm of the native arteriovenous fistula;

In FIG. 2 - stage allocation of aneurysm of arteriovenous fistula;

In FIG. 3 - aneurysm plasty stage with the formation of an auto prosthesis on a template with a diameter of 6 mm.

In FIG. 4 - stage of reinforcing the prosthesis with a thin-walled perforated prosthesis.

The method is as follows.

Under conduction, or local, anesthesia, a skin incision is performed along the aneurysmically altered portion of the arteriovenous fistula. Anastomosis of arteries and veins, the entire aneurysmally altered vein to an intact site is isolated. A clamp is applied to the site of the anastomosis, the arteriovenous anastomosis is divided, an aneurysmally altered vein is excised. A longitudinal venotomy is made along the posterior wall of the vessel, which further ensures the location of the vascular suture along the posterior wall. Purify the lumen of the aneurysm from thrombotic masses. An internal cylindrical template with a diameter of 6 mm is placed into the lumen of the vein, excess aneurysmally altered veins are excised. The vein on the template is sutured with a continuous vascular suture with an atraumatic needle, thread 6/0, with the formation of an autovenous prosthesis of cylindrical shape. The formed autoprosthesis is reinforced with an external thin-walled exoprosthesis with a diameter of 12 mm, with a perforated wall thickness of up to 0.02 mm.

The diameter of the exoprosthesis depends on the wall thickness of the aneurysm. With a vein thickness less than 2 mm, the diameter of the exoprosthesis is 10 mm, with a thickness of 2 mm or more, the diameter of the exoprosthesis is 12 mm. Using a tunnel, the reconstructed vein is placed in a new bed in a straight line directly under the skin, to a depth of 3 mm from its surface. Again form an anastomosis between an artery and a vein. The bed of extracted aneurysm is actively drained and sutured in layers.

Information sources

1. Pasklinsky G, Meisner RJ, Labropoulos N, et all. Management of true aneurysms of hemodialysis access fistulas. J Vase Surg. 2011 May; 53 (5): 1291-7. doi: 10.1016 / j.jvs.2010.11.1.100. Epub 2011 Jan 26. PubMed PMID: 21276676.

2. Lo HY, Tan SG. Arteriovenous fistula aneurysm - plicate, not ligate. Ann Acad Med Singapore 2007; 36: 851-3.

3. Reinforced Aneurysmorrhaphy for True Aneurismal Hemodialysis Vascular Access, S. Rokosny, P. Balaz, P. Wohlfahrt, D. Palous, L. Janousek, 2014.

Claims (3)

1. A method of surgical treatment of aneurysms of native vascular access, including a skin incision along the aneurysmically altered section of the arteriovenous fistula, isolation of the anastomosis of the artery and vein, aneurysmically altered veins to the intact region, clamping the anastomosis, dissection of the arteriovenous anastomosis and excision of the aneurysm, internal template, venotomy, laying the vessel in the bed, with the formation of an anastomosis between the artery and vein, characterized in that it again An autoprosthesis with a thin-walled aneurysm, with a vein thickness up to 2 mm, is reinforced with an external thin-walled exoprosthesis with a diameter of 10 mm, with a perforated wall thickness of up to 0.02 mm. 2. A method for the surgical treatment of native vascular access aneurysms includes a skin incision along the aneurysmically altered section of the arteriovenous fistula, the allocation of an anastomosis of the artery and vein and the aneurysmically changed vein to the intact section, the clamping of the anastomosis, the dissection of the arteriovenous anastomosis and the separation of the aneurysmically altered vein, using internal and external templates, venotomy, laying a vessel in a bed, with the formation of an anastomosis between an artery and a vein, excellent This is because a newly formed autoprosthesis with a thick-walled aneurysm, with a vein thickness of more than 2 mm, is reinforced with an external thin-walled exoprosthesis with a diameter of 12 mm, with a perforated wall thickness of up to 0.02 mm. 3. The method according to PP. 1, 2, characterized in that the venotomy is performed along the posterior wall of the vessel, the thrombotic masses of the aneurysm are cleaned, the aneurysmal vein is excised using an internal template with a diameter of 6 mm, the formed reinforced autoprosthesis is laid straight into the new bed, to a depth of 3 mm from the surface skin.

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