RU2734141C1 - Method for surgical removal of cava-filter through retroperitoneal miniaccess - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to vascular surgery. Skin incision line is 2–4 cm lateral to median line, 6 cm long, ending the lower edge at the navel level. Rectus muscle is moved back medially, a posterior wall of rectus sheath is dissected, a parietal peritoneum is stripped to an inferior vena cava, liver mirrors are established. Inferior vena cava is prepared with scissors upwards to the upper pole of the cava filter and down to the lower pole. Blood flow along the inferior vena cava is covered with vascular clamps in the proximal direction and distal from the cava filter (CF). Clamps are applied on the renal and lumbar veins along the anterior surface of the inferior vena cava. In a projection of a cava filter a longitudinal venotomy is performed. After the cava filter is visualized, its legs are separated from the walls of the inferior vena cava, its removal is performed; within the longitudinal incision, an endophlebectomy is performed with a vascular trowel. Vascular clamps are repeatedly inserted from the inferior vena cava, from its distal and proximal parts. Lumen of the inferior vena cava, within the longitudinal venotomy, is washed with a solution of sodium chloride 0.9 % from a syringe with volume 20 ml of a jet. Longitudinal venotomy of the inferior vena cava is closed with a continuous suture "Prolen" 5/0. Vascular clamp is removed from a distal portion of the inferior vena cava to form nodes, and a final node consisting of 6 to 8 nodes is formed. Proximal clamp and vascular clamps "bulldogs" are removed from the inferior vena cava and lumbar veins. Wound is reinforced with separate suturing of the transverse fascia, posterior and anterior walls of rectus abdominis muscle, the subcutaneous fat is closed with separate interrupted sutures, and the skin – with continuous intradermal suture from the absorbable synthetic thread.

EFFECT: method enables reducing late complications of cava filter implantation; includes the cancellation of lifelong oral anticoagulants in the absence of genetic thrombophilia, reduced risk of complications during pregnancy and delivery, as well as the possibility of effective stenosis of stenosed underlying cavities of the inferior vena cava, including in May–Thurner syndrome.

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Description

The invention relates to medicine, namely to vascular surgery, and can be used for the prevention of late complications of implantation of the "cava filter" (CF).

Pulmonary embolism (PE) has been a major clinical problem for many years. Significant prospects for the prevention of pulmonary embolism and the treatment of phlebothrombosis in the inferior vena cava (IVC) system open endovascular catheter interventions and, first of all, CF implantation. However, these interventions can lead to adverse consequences. Complications can occur during implantation, filter removal, or in the long term. The longer the filter is in the body, the more complications may arise. These are filter migration or embolization with its fragments (from 3% to 69%), and stratum fracture, and perforation (from 9% to 24%). Complications may manifest as inferior vena cava syndrome (thrombosis from 6% to 30%), postthrombophlebitic syndrome (from 5% to 70%), deep vein thrombosis (from 0% to 20%), and recurrent pulmonary embolism (from 3% up to 7%) [1]. The large number of complications associated with the long-term presence of CF in the inferior vena cava indicates the need to develop a new method for its removal in the long term with minimal complications.

There are several methods of surgical removal of CF. One of them is X-ray endovascular access with catheterization of the subclavian, or right internal jugular vein, through which the cannula is passed into the IVC 3-4 cm above the filter hook. Cavagraphy is performed through the cannula, during which the presence, or absence, of thrombotic masses under the filter, as well as the perforation of the IVC wall by its rays is established. The fixation catheter is advanced through the cannula until its tips protrude from the cannula by 2-3 cm. After pressing the handle of the fixation catheter, the loop comes out of it, opens, and is positioned at a right angle to the IVC axis. Under the control of X-ray television, the loop is put on the KF hook, the catheter-fixation is advanced caudally until the loop and the hook are pulled into the instrument lumen, thus ensuring their reliable fixation. A cannula is put on the filter fixed to the catheter with a forward motion, without force. In this case, the CF rays are gradually folded, removed from the vein wall, and it is completely inside the cannula. The filter is removed. At the final stage, control cavagraphy is performed [2]. The disadvantage of X-ray endovascular access is the lack of the possibility of gripping with a loop, or with a clamp, the removal tool of the hook of the removable CF when it is tilted. It is almost impossible to grab the hook with a loop if it rests on the vein wall. With this access, it is impossible to remove permanent cava filters, which become covered with neontima over a long period of stay in the vena cava, or its legs perforate the walls of the inferior vena cava. The optimal period for the presence of CF in the IVC, and therefore for its removal, is up to 4 weeks. It is unacceptable to remove the cava filter in case of thromboembolism, when the emboli exceed a diameter of 10 mm, in this case, the risk of PE increases.

The known method of laparoscopic removal of the cava filter, in which surgical interventions are performed in a planned manner. Laparoscopic access to the prerenal IVC, post-colorectal phlebotomy for 1.5 mm, removal of CF from the cavity of the inferior vena cava are performed. The phlebotomy hole is sutured intracorporeally with Surgipro 3-0 thread [3]. The disadvantages of this approach are the lack of control over the fragmentation of the cava filter, the impossibility of performing endophlebectomy from the inferior vena cava after CF removal, and a high risk of PE after CF removal with fragments of postthrombotic thickened intima of the inferior vena cava. There is a high risk of damage to the walls of the inferior vena cava and adjacent organs by the filter legs, which can lead to massive blood loss, since it is impossible to stop bleeding from such an access due to technical restrictions.

As a prototype, we have chosen a method of transperitoneal removal of the filter from the inferior vena cava, including endotracheal anesthesia, right-sided subcostal access, with layer-by-layer opening of the abdominal cavity, with mobilization of the duodenum according to Kocher. In the infrarenal part of the inferior vena cava, visually and palpation, the cava filter is determined. Allocate infrarenal, renal, suprarenal parts of the inferior vena cava, right gonadal and renal veins. The infrarenal section of the inferior vena cava distal to the filter, the suprarenal section, and the renal veins are taken into turnstiles. The right gonadal vein is transected and ligated. The turnstiles are tight. A longitudinal phlebotomy is performed over a filter with a length of about 30 mm. The filter is mobilized and removed from the lumen of the inferior vena cava [5]. The disadvantage of this method is its high trauma, late activation of the patient, while postoperative hematomas are relatively often observed. The postoperative period is often accompanied by paresis of the stomach and intestines. In debilitated, emaciated patients, an eventration may occur.

The purpose of the invention is to create a method for the safe removal of CF from NPS in the long term.

The essence of the invention consists in a set of essential features that ensure the achievement of the desired technical result, which consists in reducing the late complications of cava filter implantation, such as: CF thrombosis with the possible development of PE; IVC syndrome; damage to the IVC walls by elements of the filtering device, with their penetration into the retroperitoneal structures; fragmentation of CF; distal, or proximal, migration of the filter, or its fragments, to the right heart and pulmonary arteries, with the possible development of myocardial perforation and cardiac tamponade [4]. The sought-after technical result includes the abolition of lifelong intake of oral anticoagulants, in the absence of genitic thrombophelia, a decrease in the risk of complications during pregnancy, and during childbirth, as well as the possibility of effective stenting of stenotic inferior vena cava, including in Mayo-Turner syndrome.

The essence of the method of surgical removal of the cava filter through the retroperitoneal mini-access includes an incision of the skin on the abdomen on the right, isolation of the inferior vena cava, and removal of the cava filter. The skin incision line is made 2-4 cm lateral to the midline, 6 cm long, ending with the lower edge at the level of the navel. The rectus muscle is pushed medially, the posterior wall of the rectus abdominis sheath is dissected, the parietal peritoneum is peeled off to the inferior vena cava, liver mirrors are installed. The inferior vena cava is prepared with scissors up to the upper pole of the cava filter, and down to the lower pole. The blood flow through the inferior vena cava is blocked with vascular clamps proximal and distal to the cava filter. Clamps are applied to the renal and lumbar veins, along the anterior surface of the inferior vena cava, in the projection of the cava filter, and a longitudinal venotomy is performed. After visualization of the cava filter, its legs are separated from the walls of the inferior vena cava, it is removed, and endophlebectomy with a vascular spatula is performed within the longitudinal section. The blood flow is started from the inferior vena cava, from its distal and proximal, departments, vascular clamps are reapplied. The lumen of the inferior vena cava, within the longitudinal venotomy, is washed with a solution of sodium chloride 0.9% from a syringe, 20 ml volume, jet. The longitudinal venotomy of the inferior vena cava is sutured with a continuous suture using the "Prolen" 5/0 suture. The vascular clamp is removed from the distal part of the inferior vena cava before the nodes are formed, the final node is formed, consisting of 6-8 nodes. The proximal forceps are removed and the bulldog vascular forceps are removed from the inferior vena cava and lumbar veins. The wound on the abdomen is strengthened by separate suturing of the transverse fascia, posterior and anterior, walls of the rectus abdominis sheath, the subcutaneous fat is sutured with separate interrupted sutures, and the skin is sutured with a continuous intradermal suture made of absorbable synthetic thread.

The procedure for flushing the lumen of the inferior vena cava within the longitudinal venotomy, if necessary, is repeated.

The location of the skin incision on the abdomen to the right of the midline, retreating outward by 2-4 cm, is due to the location of the inferior vena cava to the right of the spine, provides better visualization of the inferior vena cava, and depends on the patient's constitution, is palpated along the outer edge of the rectus abdominis muscle.

The 6 cm incision provides access to the inferior vena cava with the instrument, the view in the wound, and the implementation of manipulations in it.

Making an incision of a small length ensures the absence of intersection of muscles, vessels and nerves of the anterior abdominal wall, which makes it possible to reduce the invasiveness of the operation and, as a result, leads to a reduction in the duration of treatment and rehabilitation, and a decrease in the number of complications.

The use of liver mirrors allows you to increase the view in the wound, facilitates the manipulation of the instrument.

Dissection of the inferior vena cava with scissors up to the upper pole of the cava filter and down to the lower pole provides access to the CF.

Blocking the blood flow along the inferior vena cava with vascular clamps proximal and distal to the cava filter, applying clamps to the renal and lumbar veins, allows blocking the blood flow in order to ensure adequate removal of CF, and the ability to control the movement of fragments.

Longitudinal venotomy along the anterior surface of the inferior vena cava in the projection of the cava filter, after its visualization, and the separation of the legs from the walls of the inferior vena cava, ensures the removal of the CF, excluding its fragmentation.

Performing endophlebectomy with a vascular spatula within the longitudinal section allows you to clear the vein from both cava filter fragments and neointima, and revise the purity of the IVC lumen for the presence of emboli.

The start of blood flow from the inferior vena cava, from its distal, and proximal, departments is performed to control emboli and IVC thrombosis.

Reapplication of the vascular forceps allows the suturing of the longitudinal venotomy.

The lumen of the inferior vena cava, within the longitudinal venotomy, is washed with a solution of sodium chloride 0.9% from a syringe, with a volume of 20 ml, jet - to eliminate emboli in the process of starting blood flow, repeat the procedure in the presence of clot residues.

The longitudinal venotomy of the inferior vena cava is sutured with a continuous suture using the Prolen 5/0 suture to eliminate the defect of the vein.

Removing the vascular clamp from the distal part of the inferior vena cava - before the formation of nodes, ensures that the vein is filled with blood and assumes its shape, excludes stenosis of the inferior vena cava.

Formation of the end node, consisting of 6-8 nodes, ensures its reliability.

Removal of the proximal forceps, and vascular "bulldog" forceps, from the inferior vena cava and lumbar veins, provides the flow of venous blood to the patient's organs.

Strengthening the wound on the abdomen with separate suturing of the transverse fascia, the posterior and anterior walls of the vagina of the rectus abdominis muscle, and suturing of the subcutaneous fat with a continuous intracutaneous suture from an absorbable synthetic thread, reduces the number of complications, reduces the duration of treatment and rehabilitation, and gives the postoperative wound a cosmetic appearance.

The method is explained by the following illustrations, where

FIG. 1 shows the location of the incision line on the abdomen;

The arrows show:

Figure 2 is a cut line of the skin and subcutaneous fat on the stomach on the right, outward about 4 cm from the midline, the length of the cut is 6 cm, the lower edge of the cut ends at the level of the navel;

FIG. 3 - prepared inferior vena cava;

FIG. 4 - longitudinal section on the inferior vena cava in the area of the cava filter;

FIG. 5 - endophlebectomy from the inferior vena cava;

FIG. 6 - vascular continuous suture on the inferior vena cava.

The method is carried out as follows.

Under intubation anesthesia, the patient is placed on the operating table, brought to a lateral position on the left side, at an angle of 45 °. The skin incision line is made 2-4 cm lateral to the midline, 6 cm long, ending with the lower edge at the level of the navel. The rectus muscle is pushed medially, the posterior wall of the rectus abdominis sheath is dissected, the parietal peritoneum is peeled off to the inferior vena cava, liver mirrors are installed. The inferior vena cava is prepared with scissors up to the upper pole of the cava filter, and down to the lower pole. The blood flow through the inferior vena cava is blocked with vascular clamps proximal and distal to the cava filter. Clamps are applied to the renal and lumbar veins, along the anterior surface of the inferior vena cava, in the projection of the cava filter, a longitudinal venotomy is performed. After visualization of the "cava filter", its legs are separated from the walls of the inferior vena cava, followed by its complete removal from the inferior vena cava using vascular forceps. Within the limits of the longitudinal section, endophlebectomy is performed with a vascular spatula. The blood flow is started from the inferior vena cava, from its distal and proximal, departments, vascular clamps are reapplied. The lumen of the inferior vena cava, within the longitudinal venotomy, is washed with a solution of sodium chloride 0.9% from a syringe with a volume of 20 ml, jet, if necessary, repeat the procedure. The longitudinal venotomy of the inferior vena cava is sutured with a continuous suture using the "Prolen" 5/0 suture. The vascular clamp is removed from the distal part of the inferior vena cava before the nodes are formed, the final node is formed, consisting of 6-8 nodes. The proximal forceps are removed, and the bulldog vascular forceps from the inferior vena cava and lumbar veins are removed. The wound on the abdomen is strengthened by separate suturing of the transverse fascia, posterior and anterior, walls of the rectus abdominis sheath, the subcutaneous fat is sutured with separate interrupted sutures, and the skin is sutured with a continuous intradermal suture made of absorbable synthetic thread.

Clinical example 1

Patient C, 28 years old, was admitted to the Department of Vascular Surgery of the Main Clinical Hospital No. 7 of Kazan on 11.11.2019 with complaints of swelling of the left leg and foot, periodic bursting pain in the lumbar region. Disease duration is about 6 months. History of post-thrombophlebitic disease of the left lower extremity. Transferred, about 6 months ago, thrombosileofemoral segment on the left with flotation of the thrombus head into the left common iliac vein. On May 31, 2019, for health reasons, on an emergency basis, an operation was performed: the installation of a cava filter. Physical examination revealed edema of the left leg (leg +2 cm). Palpation of the calf muscles is painless. The pulsation on the main vessels was determined throughout. An ultrasound examination (US) of the veins of the lower extremities was performed: LEFT: the common iliac vein is stained with color duplex scanning (CDS). The external iliac vein is not dilated, segmental with parietal and central recanalization canals. The patency of superficial veins is not impaired. Deep femoral veins are patent. In the common femoral and superficial femoral veins, hyperechoic heavy thrombomasses are visualized, which are not completely compressed during compression. The posterior tibial veins and the popliteal vein are not dilated, fully compressible, the lumen is free. RIGHT: the patency of the main superficial and deep veins is not impaired. Performed X-ray computed tomography (CT) with contrasting of the inferior vena cava. Conclusion: the inferior vena cava is patent. The cava filter is located at the level of the renal veins; no evidence of thrombosis of the cava filter has been identified. Based on the examination, the clinical diagnosis was made: Postthrombophlebitic disease of the superficial femoral, common femoral, external iliac, common iliac veins of the left lower extremity in the stage of partial recanalization. Installation of the cava filter 05/31/2019 Secondary lymphostasis of the left lower limb. The patient underwent surgery on November 14, 2019, 1210-1320: Removal of the cava filter through the retroperitoneal mid-access. Retroperitoneal mini-access to the inferior vena cava was performed under intubation anesthesia by dissecting the skin, subcutaneous fat, and the anterior wall of the rectus sheath. The skin incision line was made on the right, approximately 2 cm lateral (outward) to the midline, 6 cm long, the lower edge of the incision was completed at the level of the navel, since the cava filter migrated to the level of renal vein discharge. The rectus muscle was pushed medially, the posterior wall of the rectus sheath was dissected. The parietal peritoneum was detached to the inferior vena cava, liver mirrors were installed. The inferior vena cava was prepared with scissors up to the upper pole of the cava filter, and down to the lower pole. After preliminary administration of the Heparin solution, based on body weight, the blood flow through the inferior vena cava was blocked with vascular clamps proximal and distal to the cava filter. Separately, clamps were applied to the renal and lumbar veins. A longitudinal venotomy was performed with a scalpel along the anterior surface of the inferior vena cava, in the projection of the cava filter. After visualization of the "cava filter", its legs were separated from the walls of the inferior vena cava, and it was completely removed from the inferior vena cava with vascular forceps. Endophlebectomy was performed with a vascular spatula within the longitudinal section. Before suturing the transverse venotomy, the blood flow was started from the inferior vena cava, from its distal, and proximal, departments, to control emboli. After starting the blood flow, within the longitudinal venotomy, the lumen of the inferior vena cava was washed with a solution of sodium chloride 0.9% from a syringe with a volume of 20 ml, jet. The longitudinal venotomy of the inferior vena cava was sutured with a continuous suture with 5/0 Prolen suture. Before the formation of the end node, in order to exclude stenosis of the inferior vena cava, a vascular clamp was removed from the distal part of the inferior vena cava to fill the vein with blood and take its shape, and the end node of 7 nodes was formed. The proximal forceps and the bulldog vascular forceps from the inferior vena cava and lumbar veins were removed. The wound on the abdomen was strengthened by separate suturing of the transverse fascia, the posterior and anterior walls of the rectus sheath, the subcutaneous fat was sutured with separate interrupted sutures, and the skin was sutured with a continuous intradermal suture made of absorbable synthetic thread. Blood loss 350 ml.

During the operation, there were no technical difficulties with the isolation of the inferior vena cava. After the operation, the patient was in the intensive care unit for 5 hours. Transferred to the Department of Vascular Surgery. 11/15/2019, on control CT with contrasting of the inferior vena cava, and deep veins of the lower extremities, data for the threat of pulmonary vein thromboembolism and retrombosis of the iliac and inferior vena cava were not revealed. The postoperative period was without complications. The patient was discharged from the vascular surgery department of GAUZ City Clinical Hospital No. 7 on the 7th day after surgery, with recommendations, under the supervision of a vascular surgeon at the place of residence. On June 25, 2019, VAT was performed on the inferior vena cava - no data were found for violations of the inferior vena cava patency.

Clinical example 2

Patient P., 28 years old, was admitted to the Department of Vascular Surgery of the Main Clinical Hospital No. 7 of Kazan on May 21, 2019 with complaints of swelling of the left leg and foot. Disease duration is about 3 months. History - post-thrombophlebitic disease of the left lower limb. She suffered, about 3 months ago, PE, thrombosis of the ileofemoral segment on the left, with flotation of the thrombus head into the left common iliac vein. On April 23, 2019, according to vital indications, on an emergency basis, an operation was performed: Installing a cava filter. Physical examination revealed swelling of the left leg (shin + 1.5 cm). Palpation of the calf muscles is painless. The pulsation on the main vessels is determined throughout. The CT was performed with contrasting of the inferior vena cava. Conclusion: the inferior vena cava is patent. The cava filter is located 0.5 cm below the renal veins; no evidence of thrombosis of the cava filter has been identified. In the left common and external iliac veins, a contrast defect is visualized in the form of a narrowing of the lumen up to 30%. On the basis of the examination, a clinical diagnosis was made: Postthrombophlebitic disease of the common femoral, external iliac and common iliac veins of the left lower extremity in the stage of partial recanalization. Installation of the cava filter 04/23/2019 Secondary lymphostasis of the left lower limb. 05/22/2019 1200-1600 the patient underwent surgery: Attempt to remove the cava filter by the X-ray edovascular method. The attempt was unsuccessful due to the formation of neonthyma above the kava filter. 05/23/2019 0900-1120, the operation was performed: Removal of the cava filter through the retroperitoneal mini-access from the inferior vena cava. Retroperitoneal mini-access to the inferior vena cava was performed under intubation anesthesia by dissecting the skin, subcutaneous fat, and the anterior wall of the rectus sheath. The skin incision line was made on the right, approximately 3 cm lateral (outward) to the midline, 6 cm long, the lower edge of the incision was completed at the level of the navel. The rectus muscle was pushed medially, the posterior wall of the rectus sheath was dissected. The parietal peritoneum was detached to the inferior vena cava, liver mirrors were installed. The inferior vena cava was prepared with scissors up to the upper pole of the cava filter, and down to the lower pole. After preliminary administration of the Heparin solution, based on body weight, the blood flow through the inferior vena cava was blocked with vascular clamps proximal and distal to the cava filter. Separate clamps were placed on the lumbar veins. A longitudinal venotomy was performed with a scalpel along the anterior surface of the inferior vena cava, in the projection of the cava filter. After visualization of the cava filter, its legs were separated from the walls of the inferior vena cava and its complete removal from the inferior vena cava was performed with vascular forceps. After removing the cava filter, endophlebectomy was performed with a vascular spatula within the longitudinal section. Before suturing the transverse venotomy, the blood flow was started from the inferior vena cava, from its distal and proximal, departments, to control the emboli. After starting the blood flow, within the longitudinal venotomy, the lumen of the inferior vena cava was washed with a solution of sodium chloride 0.9% from a syringe, with a volume of 20 ml, jet. The longitudinal venotomy of the inferior vena cava was sutured with a continuous suture with a 5/0 "Prole" suture. Before the formation of the end node, in order to exclude stenosis of the inferior vena cava, a vascular clamp was removed from the distal part of the inferior vena cava to fill the vein with blood and take its shape; an end node of 6 nodes was formed. The proximal forceps and the bulldog vascular forceps from the inferior vena cava and lumbar veins were removed. The wound on the abdomen was strengthened by separate suturing of the transverse fascia, the posterior and anterior walls of the rectus sheath, the subcutaneous fat was sutured with separate interrupted sutures, and the skin was sutured with a continuous intradermal suture, absorbable synthetic thread. Blood loss 200 ml

During the operation, there were no technical difficulties with the isolation of the inferior vena cava. After the operation, the patient was in the intensive care unit for 4 hours. Transferred to the Department of Vascular Surgery. On May 24, 2019, on control CT with contrasting of the inferior vena cava and deep veins of the lower extremities, there were no data for the threat of pulmonary vein thromboembolism and retrombosis of the iliac and inferior vena cava. The postoperative period was without complications. The patient was discharged from the vascular surgery department of GAUZ City Clinical Hospital No. 7 on the 12th day after the operation with recommendations, under the supervision of a vascular surgeon at the place of residence. On May 24, 2019, CDS of the inferior vena cava was performed, no data for impaired patency of the inferior vena cava were revealed.

Clinical case 3

Patient K., 49 years old, was admitted to the department of vascular surgery of the Main Clinical Hospital No. 7 of Kazan on January 13, 2020 with complaints of swelling of the left leg and foot, recurrent pain in the lumbar region on the right. The duration of the disease is about 2.5 years. History of post-thrombophlebitic disease of the left lower extremity. On July 22, 2017, she underwent thrombosis of the ileofemoral segment on the left with flotation of the thrombus head into the left common iliac vein. On July 22, 2017, for health reasons, on an emergency basis, an operation was performed: Installation of a non-removable cava filter. Physical examination revealed swelling of the left leg (shin + 1.5 cm). Palpation of the calf muscles is painless. The pulsation on the main vessels is determined throughout. On January 15, 2020, an X-ray CT was performed with contrasting of the inferior vena cava. Conclusion: a cava filter was installed in the lumen of the inferior vena cava, just below the orifices of the renal veins. The inferior vena cava with indistinct uneven contours from the level below the outlet of the left renal vein, no blood flow in the left iliac veins. Based on the examination, the clinical diagnosis was made: Postthrombophlebitic disease of the external iliac and common iliac veins of the left lower extremity without recanalization. Installation of a fixed cava filter July 22, 2017 Secondary lymphostasis of the left lower limb. The patient underwent surgery on January 21, 2020 1130-1430: Removal of the cava filter through the retroperitoneal mini-access from the inferior vena cava. Retroperitoneal mini-access to the inferior vena cava was performed under intubation anesthesia by dissecting the skin, subcutaneous fat, and the anterior wall of the rectus sheath. The skin incision line was made on the right, approximately 4 cm lateral (outward) to the midline, 6 cm long, the lower edge of the incision was completed at the level of the navel. The rectus muscle was pushed medially, the posterior wall of the rectus sheath was dissected. The parietal peritoneum was detached to the inferior vena cava, liver mirrors were installed. The inferior vena cava was prepared with scissors up to the upper pole of the cava filter, and down to the lower pole. After preliminary administration of the Heparin solution, based on body weight, the blood flow through the inferior vena cava was blocked with vascular clamps proximal and distal to the cava filter. Separate clamps were placed on the lumbar veins. A longitudinal venotomy was performed with a scalpel along the anterior surface of the inferior vena cava, in the projection of the cava filter. "Kava filter" is covered with neontime. An endophlebectomy was performed over the cava filter, the legs were separated from the walls of the inferior vena cava, and it was completely removed from the inferior vena cava with vascular forceps. After removing the "cava filter", an additional endophlebectomy was performed with a vascular spatula within the longitudinal section. Before suturing the transverse venotomy, the blood flow was started from the inferior vena cava, from its distal and proximal parts, to control the emboli. After starting the blood flow, within the longitudinal venotomy, the lumen of the inferior vena cava was washed with a solution of sodium chloride 0.9% from a syringe with a volume of 20 ml, jet. The longitudinal venotomy of the inferior vena cava was sutured with a continuous suture with 5/0 Prolen suture. Before the formation of the end node, in order to exclude stenosis of the inferior vena cava, a vascular clamp was removed from the distal part of the inferior vena cava to fill the vein with blood, and assuming its shape, an end node of 8 nodes was formed. The proximal forceps and the bulldog vascular forceps from the inferior vena cava and lumbar veins were removed. The wound on the abdomen was strengthened by separate suturing of the transverse fascia, the posterior and anterior walls of the rectus sheath, suturing the subcutaneous fat with separate interrupted sutures, and the skin with a continuous intradermal suture made of absorbable synthetic thread. Blood loss 250 ml

During the operation, there were no technical difficulties with the isolation of the inferior vena cava. After the operation, the patient was in the intensive care unit for 8 hours, then transferred to the vascular surgery unit. On January 23, 2020, on control CT with contrasting of the inferior vena cava, and deep veins of the lower extremities, there were no data for the threat of developing pulmonary vein thromboembolism, and retrothrombotic iliac and inferior vena cava. In the postoperative period, the patient maintained a febrile temperature for 3 days, on the 4th day the temperature returned to normal. The patient was discharged from the vascular surgery department of GAUZ GKB No. 7 on the 15th day after the operation with recommendations, under the supervision of a vascular surgeon at the place of residence.

Sources of information

1. A.Z. Sharafeev, L.V. Glushchenko, Modern approaches to the implantation of cava filters in the event of a threat of pulmonary thromboembolism; "News of surgery" No. 2 volume 24, 2016).

2.V.A. Ivanov, M. Yu. Movsesyants, I.V. Trunin Guide to X-ray endovascular surgery of heart and vascular diseases in three volumes, 2008.

3. Zharkiy F.N. 1, P.V. Mozgovoy 2, Spiridonov E.G. Etc. 21 FGBOU VO VolgGMU MH RF Clinic 1; 2FGBOU VO VolgGMU MH RF Clinic 1, Volgograd, RF; ZGBUZ VOKB No. 1, Volgograd, RF, Date of report: 26.11.2017 Section: Scientific-practical conference "Modern achievements of reconstructive and endovascular surgery in the treatment of diseases of the venous and lymphatic system."

4. FGBOU IN RNIMU them. N.I. Pirogov, Ministry of Health of Russia, Moscow The original article was published on the website of the Russian Medical Journal (Russian Medical Journal): https://www.rmj.ru/articles/angiologiya/Pozdnie_osloghneniya_implantacii_kava-filytrov/#ixzz6Az6hdPxn). (Regular issues of "RMZh" No. 6 (11) of 12.12.2018 pp. 79-84 Heading: Angiology Authors: Ivanov V.V., Andriyash-kin V.V.

5.acad. Ramn, MD, Prof. A.I. Kirienko *, MD, DSc, Assoc. V.V. Andriyashkin, Ph.D. Yu.N. Kolosov Department of Faculty Surgery (Head - Academician of the Russian Academy of Sciences and the Russian Academy of Medical Sciences, Prof. B.C. Savelyev), Russian National Research Medical University named after N.I. Pirogov, Moscow).

Claims (2)

1. A method of surgical removal of a cava filter through a retroperitoneal mini-access, including an incision of the skin on the abdomen on the right, isolation of the inferior vena cava, removal of the cava filter, characterized in that the skin incision line is made 2-4 cm lateral to the midline, 6 cm long, ending the lower edge at the level of the navel, the rectus muscle is pushed medially, the posterior wall of the vagina of the rectus abdominis muscle is dissected, the parietal peritoneum is exfoliated to the inferior vena cava, hepatic mirrors are installed, the inferior vena cava is dissected with scissors up to the upper pole of the cava filter and down to the lower pole , the blood flow through the inferior vena cava is closed with vascular clamps proximal and distal to the cava filter, clamps are applied to the renal and lumbar veins, along the anterior surface of the inferior vena cava, in the projection of the cava filter, a longitudinal venotomy is performed, after visualization of the "cava filter" of its legs separated from the walls of the inferior vena cava, remove it, within the longitudinal endophlebectomy is performed with a vascular spatula, blood flow is started from the inferior vena cava, from its distal and proximal sections, vascular clamps are reapplied, the lumen of the inferior vena cava, within the longitudinal venotomy, washed with 0.9% sodium chloride solution from a 20 ml syringe jet, the longitudinal venotomy of the inferior vena cava is sutured with a continuous suture "Prolen" 5/0 suture, the vascular clamp is removed from the distal part of the inferior vena cava until the nodes are formed, an end node is formed, consisting of 6-8 nodes, the proximal clamp and vascular clamps are removed. »From the inferior vena cava and lumbar veins, strengthen the abdominal wound with separate suturing of the transverse fascia, the posterior and anterior walls of the rectus sheath, suture the subcutaneous fat with separate interrupted sutures, and the skin with a continuous intradermal suture made of absorbable synthetic thread. 2. The method according to claim 1, characterized in that the procedure for flushing the lumen of the inferior vena cava within the longitudinal venotomy is repeated if necessary.

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