RU2736392C1 - Method of surgical treatment of patients with giant aortic aneurysms - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to cardiovascular surgery. After medial laparotomy, a front wall of the aneurysm of the infrarenal aorta, its neck and iliac arteries are separated. Iliac artery is ligatured or clamped. Clamp is applied on an unchanged aneurysm of the aneurysm. Aortic aneurysm clamp is longitudinally applied. Aorta is crossed transversely. Aneurismically changed aortic walls are dissected by a clamp, detritus and thrombotic masses are removed. Distal aorta portion is closed by a single-row blanket suture. Stepwise removal of longitudinal clamp, tightening threads. Proximal and distal anastomoses of aorta and synthetic prosthesis are formed.

EFFECT: method provides reliable reduction of aortic aneurysm, improved conditions for proximal anastomosis, reduced number of early and late postoperative complications in the form of a disordered configuration of the synthetic prosthesis and thrombosis, and can be performed both in planned and emergency operations.

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Description

The invention relates to medicine, namely to cardiovascular surgery. It can be used in the departments of cardiovascular surgery.

Aortic aneurysms are an urgent problem in modern cardiovascular surgery due to the high incidence and frequent asymptomatic course of the disease. Scott R. et al. (1991) detected aneurysms of the abdominal aorta during a screening examination of the population over 50 years old in 7.8% of men and 1.4% of women [1].

Aneurysms of the abdominal aorta make up 80% of all aortic aneurysms of all locations. In 89-96% of the aneurysms have infrarenal localization [2].

By size, aortic aneurysms are divided into: small aneurysms (d = 3-5 cm), medium (d = 5-7 cm), large (d more than 7 cm), giant (8-10 times larger than the diameter of the aorta) [3] ...

The natural development of the aortic aneurysm is its rupture. With an aneurysm size of more than 8 cm, the risk of rupture in the first year is 36.4%, in the second year - 54.7% [4].

The indication for surgical treatment of an aneurysm of the ascending aorta is its diameter 45-50 mm, aortic arch - 50-55 mm, thoracoabdominal section - 55-60 mm, abdominal aorta - 45-50 mm [5].

Currently, many techniques have been proposed for performing aortic prosthetics.

The known method of intra-bag prosthetics of the aortic aneurysm. In this case, clamps are applied to the aorta and iliac arteries. The aortic aneurysm is opened with a T-shaped incision, evacuating detritus and thrombotic masses. Bleeding lumbar arteries are sutured. The proximal and distal anastomoses are formed with the aorta or iliac arteries [6, 7]. The disadvantage of this method is a large volume of blood loss from both the aneurysm itself and from the functioning lumbar arteries, the risk of infection of the prosthesis in the presence of microorganisms in the aneurysmal bowl.

A method of surgical treatment of patients with aortic aneurysm without opening and excision of the aneurysm (“off”) is described [8]. With this technique, after isolation of the aorta, iliac and femoral arteries, the aorta is clamped proximal to the “neck” and distal at the level of the “neck” transition to the aneurysm. The aorta is completely transected between the clamps. Both common iliac arteries are ligated, completely "turning off" the aneurysm from the bloodstream. A proximal end-to-end anastomosis is formed with a bifurcation prosthesis. The branches of the prosthesis are brought out to the hips and distal end-to-side anastomoses are applied to the common femoral arteries. The disadvantages of this method are: use only for small aneurysms of the abdominal aorta, lack of space for the imposition of two clamps with a small "neck" of the aneurysm.

и более от начального ее объема.For the prototype of the proposed method was taken a method of surgical treatment of patients with aneurysm of the infrarenal aorta (RU 2441605) [9]. With this technique, the aortic aneurysm neck is mobilized. It is crossed between two clamps that clamp the neck of the aneurysm in its proximal part. The common iliac arteries are ligated. Then, the peripheral end of the aorta is sutured with a twisted suture with a strong prolene thread on an atraumatic needle, reducing the volume of the aneurysm by

and more from its initial volume.

With all its advantages, this method has a number of disadvantages: with aortic aneurysms having a diameter of more than 8-9 cm (giant aortic aneurysms), suturing of the peripheral end of the aorta (reduction) with a twisted suture leads to the formation of a large rigid ridge. Such a roller can interfere with the comfortable formation of the proximal anastomosis and subsequently disrupt the configuration of the retroperitoneally placed vascular prosthesis. Also, when performing a twisted suture with an unopened aneurysm, it is impossible to be sure of the complete reduction.

The aim of the invention is to introduce into clinical practice a method for the surgical treatment of patients with giant aortic aneurysms, the use of which would lead to the achievement of reliable reduction of the aortic aneurysm, improve the conditions for the formation of the proximal anastomosis, and would contribute to a decrease in the number of early and late postoperative complications in the form of a violation of the configuration of the synthetic prosthesis and its thrombosis, would not require additional material costs and would be technically feasible for both planned and emergency surgical interventions.

On the example of surgical treatment of infrarenal aortic aneurysm, the proposed method is implemented as follows. After midline laparotomy and opening of the retroperitoneal space, the anterior wall of the infrarenal aortic aneurysm, its neck and iliac arteries are isolated (Fig. 1). When the aneurysm spreads to the common iliac arteries, they are ligated with two ligatures (Fig. 2). With unchanged aortic bifurcation, it is clamped immediately over the common iliac arteries. A clamp is applied to the unchanged neck of the aneurysm (Fig. 3). Longitudinally, a long clamp is applied to the aortic aneurysm, as close as possible to its posterior wall, to prevent active bleeding from the branches extending from the aorta. Cross the aorta. The aneurysmically altered aortic walls are resected along the longitudinal forceps, detritus and thrombotic masses are removed (Fig. 4). The distal aorta is sutured with a single-row twisted suture with the obligatory pickup of the posterior wall of the aorta under visual control (Fig. 5). Remove the longitudinal clamp by tightening the threads (Fig. 6). A proximal anastomosis of the aorta and a linear or bifurcated synthetic prosthesis is formed. The clamp is removed from the aorta and transferred to the prosthesis. A distal anastomosis of a synthetic prosthesis and aorta is formed with linear prosthetics or distal anastomosis of the branch with the iliac or femoral arteries with bifurcation prosthetics. The clamps are removed and the blood flow is started (Fig. 7).

Clinical examples illustrating the successful application of this method in the treatment of patients with aortic pathology are presented below.

Example 1. Patient K., 64 years old, was admitted to the Department of Vascular Surgery No. 1 of the Clinic of Faculty Surgery of Samara State Medical University on February 25, 2019 with complaints of a pulsating abdominal mass, recurrent pain in the upper abdomen, shortness of breath with moderate physical exertion, an increase in blood pressure to 180 and 90 mm Hg. According to CT angiography, an aneurysm of the infrarenal aorta with a diameter of up to 90 mm is determined without spreading to the iliac arteries. The clinical diagnosis was established: Aneurysm of the infrarenal aorta. Ischemic heart disease, myocardial infarction (2014). Coronary stenting (2014). Arterial hypertension grade III, grade 3, risk 4. HI (NYHA II). Erosive gastrobulbitis COPD, moderate severity, DNI. Osteochondrosis of the thoracic spine. The patient was taken to the operating room. Median laparotomy. The posterior peritoneum is dissected. A fusiform aneurysm of the infrarenal aorta with a diameter of 90 mm and a length of 100 mm is determined. In the proximal section, it begins 3 cm distal to the renal arteries. It ends distally 2 cm above the aortic bifurcation. The anterior wall of the infrarenal aortic aneurysm, its neck and common iliac arteries were highlighted. A clamp is placed on the aortic bifurcation immediately above the common iliac arteries. A clamp is placed on the unchanged neck of the aneurysm. A clamp is placed longitudinally on the aortic aneurysm. The aorta is transversely transected. Aneurysmically altered aortic walls were resected along the longitudinal forceps, detritus and thrombotic masses were removed. The distal part of the aorta was sutured with a single-row twisted suture and the posterior wall of the aorta was grasped with the Prolen 2/0 thread. The longitudinal clamp with thread tightening is removed. Formed a proximal anastomosis of the aorta and linear synthetic prosthesis with Prolen 4/0 thread. The clamp was removed from the aorta and transferred to the prosthesis. Formed distal anastomosis of the aorta and linear synthetic prosthesis with Prolen 4/0 thread. Deaeration. Removing clamps and starting blood flow.

The configuration of the prosthesis is satisfactory. Suturing of postoperative wounds in layers. Aseptic dressing. The postoperative period was uneventful. Healing wounds by primary intention. The patient was discharged on the 10th day.

Example 2. Patient Ch., 76 years old, was admitted to the Department of Vascular Surgery No. 1 of the Clinic of Faculty Surgery of the Samara State Medical University on April 22, 2019 with complaints of the presence of a pulsating formation in the umbilical region, a periodic increase in blood pressure, shortness of breath with moderate exercise, general weakness. According to CT angiography, an aneurysm of the infrarenal aorta with a diameter of 80 mm with extension to the common iliac arteries is determined. The clinical diagnosis was established: Aneurysm of the abdominal aorta. Atherosclerosis of the aorta and its branches. Stenosis of the carotid arteries on both sides. Coronary artery bypass grafting after coronary artery bypass grafting (IHD) (2019). RCA stenting (2002). Insufficiency of the mitral valve 1-2 tbsp. Atrial fibrillation, paroxysmal form. Transient AV-blockade of the 1st stage. Arterial hypertension of the 3rd stage, 3rd stage, risk 4. НIIА (NYHA III). Moderate pulmonary hypertension. Hypertensive heart. The patient was taken to the operating room. Median laparotomy. The posterior peritoneum is dissected. A fusiform aneurysm of the infrarenal aorta with a diameter of 80 mm and a length of 90 mm is determined, spreading to the initial parts of the common iliac arteries. In the proximal section, it begins 4 cm distal to the renal arteries. The anterior wall of the infrarenal aortic aneurysm, its neck and common iliac arteries were highlighted. The common iliac arteries are tied with two ligatures. A clamp is placed on the unchanged neck of the aneurysm. A clamp is placed longitudinally on the aortic aneurysm. The aorta is transversely transected. Aneurysmically altered aortic walls were resected along the longitudinal forceps, detritus and thrombotic masses were removed. The distal part of the aorta was sutured with a single-row twisted suture and the posterior wall of the aorta was grasped with Prolen 2/0 thread. The longitudinal clamp with thread tightening is removed. Formed a proximal anastomosis of the aorta and bifurcated synthetic prosthesis with Prolen 4/0 thread. The clamp was removed from the aorta, clamps were applied to the branches of the bifurcation prosthesis. Distal anastomoses were formed between the branches of the bifurcation prosthesis and the common iliac arteries with Prolen 6/0 threads. Deaeration. Removing clamps and starting blood flow. The configuration of the prosthesis is satisfactory. Suturing of postoperative wounds in layers. Aseptic dressing. The postoperative period was uneventful. Healing wounds by primary intention. The patient was discharged on the 11th day.

Below is an example illustrating the use of this method in the surgical treatment of aneurysms of both the abdominal and thoracic aorta.

Example 3. Patient E., 54 years old, was admitted to the Department of Vascular Surgery No. 1 of the Clinic of Faculty Surgery of Samara State Medical University on an emergency basis with complaints of pain in the right iliac region, thoracic and lumbar spine, with a rise in body temperature of 38-39 C. CT angiography revealed an aneurysm of the abdominal aorta with signs of rupture, retroperitoneal hematoma, and aneurysm of the thoracic aorta. The clinical diagnosis was established: Aneurysm of the abdominal aorta with signs of rupture. Retroperitoneal hematoma. Aneurysm of the descending thoracic aorta. Atherosclerosis of the aorta and its branches.

Urgently taken to the operating room. Median laparotomy; the posterior peritoneum is dissected. An aneurysm of the infrarenal aorta with dimensions of 80 × 60 cm is determined. The aneurysm of the infrarenal aorta, its neck and common iliac arteries are highlighted. A clamp is placed on the aortic bifurcation immediately above the common iliac arteries. A clamp is placed on the unchanged neck of the aneurysm. A clamp is placed longitudinally on the aortic aneurysm. The aorta is transversely transected. Aneurysmically altered aortic walls were resected along the longitudinal forceps, detritus and thrombotic masses were removed. The distal part of the aorta was sutured with a single-row twisted suture and the posterior wall of the aorta was grasped with the Prolen 2/0 thread. The longitudinal clamp with thread tightening is removed. Formed a proximal anastomosis of the aorta and linear synthetic prosthesis with Prolen 4/0 thread. The clamp was removed from the aorta and transferred to the prosthesis. Formed distal anastomosis of the aorta and linear synthetic prosthesis with Prolen 4/0 thread. Deaeration. Removing clamps and starting blood flow. The configuration of the prosthesis is satisfactory. Suturing of postoperative wounds in layers. Aseptic dressing. The patient's condition remained stable until 17:00 on the same day, when profuse vomiting of liquid blood with clots developed in the intensive care unit. The situation was regarded as rupture of the thoracic aortic aneurysm with the formation of an aortoesophageal fistula. The patient was urgently taken to the operating room. Anterolateral thoracotomy on the left in the VI intercostal space. In the pleural cavity, fresh blood is determined in a volume of 300 ml, dried. The imbibition of the paraaortic space is determined. At 16 cm below the level of the left subclavian artery, an aneurysm of the thoracic aorta measuring 80 × 60 mm is determined, intimately adhered to the esophagus, isolated from the surrounding tissues. Clamps were placed above and below the aneurysm. A clamp is placed longitudinally on the aortic aneurysm. The aorta is transversely transected. Aneurysmically altered aortic walls were resected along the longitudinal forceps, detritus and thrombotic masses were removed. The distal part of the aorta was sutured with a single-row twisted suture and the posterior wall of the aorta was grasped with Prolen 2/0 thread. The longitudinal clamp with thread tightening is removed. Formed a proximal anastomosis of the aorta and linear synthetic prosthesis with Prolen 4/0 thread. The clamp was removed from the aorta and transferred to the prosthesis. Formed distal anastomosis of the aorta and linear synthetic prosthesis with Prolen 4/0 thread. Deaeration. Removing clamps and starting blood flow. The configuration of the prosthesis is satisfactory. Suturing of postoperative wounds in layers. Aseptic dressing. The postoperative period was accompanied by symptoms of recurrent hydrothorax on the left; punctures of the pleural cavity were performed. Healing wounds by primary intention. The patient was discharged on the 28th day.

In the department of vascular surgery No. 1 of the clinic of the faculty of surgery of the Samara State Medical University, over the past 2 years, 10 surgical interventions with prosthetics of giant infrarenal aortic aneurysms were performed according to the proposed method. In all patients, the postoperative period was uneventful. In the long-term period, changes in the configuration of the synthetic prosthesis, its thrombosis were not observed in any patient.

The advantages of the proposed method are:

1. Absence of formation of a large rigid cushion in the area of reduction of the aortic aneurysm.

2. Reliable suturing of the distal aorta with obligatory grasping of the posterior aortic wall under visual control.

3. Improving the conditions for the formation of the proximal and distal anastomosis of the aorta and synthetic prosthesis.

4. Absence of disruption of the configuration of a synthetic prosthesis and, as a consequence, a decrease in the risk of its thrombosis in the long-term postoperative period.

5. Possibility of application both for planned and emergency surgical interventions

6. Does not require additional technical support and material costs.

7. Elimination of the true aneurysmically altered aortic lumen and complete removal of altered aortic tissues and thrombotic masses, thereby reducing inflammation in the postoperative period and reducing the risk of paraprosthetic hematomas formation.

The proposed method and features distinguishing it from the known techniques have not been found in the medical and patent literature.

LIST OF REFERENCES

1. Scott R.A., Gudgeon A.M., Ashton H.A., Allen D.R., Wilson N.M. Surgical workload as a consequence of screening for abdominal aortic aneurysm. Br J Surg. 1994 Oct; 81 (10): 1440-2.

2. Clinical angiology. Guide for Physicians / Ed. A.V. Pokrovsky. In two volumes. - T. 2. - M .: "Medicine", 2004. - 888 p: ill.

3. Spiridonov A.A., Tutov E.G., Arakelyan B.C. Surgical treatment of abdominal aortic aneurysms. M .: Publishing house of the NTSSSH im. A.N. Bakuleva RAMS, 2000.206 p.

4. Lederle F. A. The Natural History of Abdominal Aortic Aneurysm. Acta Chirurgica Belgica. 2009; 109 (1): 7-12.

5. Clinical guidelines for the diagnosis and treatment of aortic diseases (2017). Cardiology and Cardiovascular Surgery. 2018; 11 (1): 7-67.

6. Belov Yu.V. A guide to vascular surgery with an atlas of operative techniques. - 2nd ed., Rev. and additional - M., 2011 .-- 464 p.

7. Vascular surgery according to Haimovich. Ed. E. Asher. Translation of the 5th English edition, ed. A.V. Pokrovsky. In two volumes. - T. 2. - M .: "Binom", 2012.-534 p.

8. Kazanchyan P.O., Popov V.A. Complications in surgery of abdominal aortic aneurysms. - M .: Publishing house MEI, 2002 .-- 304 p.

9. The method of surgical treatment of patients with aneurysm of the infrarenal aorta: Pat. 2441605 Russian Federation: IPC A61 B 17/00 / Vachev AN, Novozhilov AV. - No. 2010140079/14; declared 09/29/2010; publ. 10.02.2012, Bul. No. 4.

Claims (1)

A method of surgical treatment of patients with giant aortic aneurysms, which consists in performing prosthetics of the aorta and characterized by longitudinal clamping of the aortic aneurysm, resection of the aneurysmically altered aortic walls by clamping, suturing the remaining aortic tissues with a single-row twisted suture with obligatory grasping of the posterior aortic wall under visual control, removal of the longitudinal clamps with thread tightening and linear or bifurcated aortic prosthetics.

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