RU2741695C2 - Method for strengthening a proximal anastomosis of a synthetic prosthesis with the abdominal and thoracic aorta with a telescopic cuff - Google Patents

Abstract

FIELD: medicine; cardiovascular surgery.

SUBSTANCE: preliminary eversion of a vascular prosthesis in a zone of proximal anastomosis is performed to form a cuff from a prosthesis. Further, the proximal anastomosis is formed by a continuous blanket suture. After the anastomosis is formed before the blood flow is started, the cuff is expanded so that the cuff closes the proximal anastomosis area, and the blood flow is started. After the blood flow starts, an independent stretching of the synthetic prosthesis occurs. Further, the cuff is reduced along the front wall by sutured suture with prolene suture 5/0 on a non-traumatic needle in the longitudinal direction.

EFFECT: method enables to strengthen the proximal anastomosis of the synthetic prosthesis with the abdominal and thoracic aorta, as well as reduce the number of postoperative aneurysms of the proximal anastomosis in the distant period.

1 cl, 5 dwg, 1 ex

Description

The invention relates to medicine, namely to cardiovascular surgery and can be used in the operation of prosthetics of the thoracic or abdominal aorta, both in patients with aortic aneurysm, and in patients with literating diseases of the aorta.

In the "Guide to vascular surgery with an atlas of operative techniques" Yu.V. Belova (2000), described 4 methods for creating a hermetic anastomosis of the prosthesis with the aorta. The method using a synthetic strip-pad, the use of a double-row suture or double continuous twisting suture, the use of an outer support ring at the anastomosis.

The disadvantages of the described methods should be recognized that the risk of developing a proximal anastomosis aneurysm in the postoperative period remains. According to the literature, the incidence of this complication after aortic replacement surgery is observed in 0.2-10% of patients (Paolo Bianchi, Yonsei Med J 50 (2): 227-238, 2009).

The technical result to be achieved by the creation of this invention is to improve the efficiency of treatment of patients with aneurysm of the thoracic and / or abdominal aorta by reducing the number of postoperative aneurysms of the proximal anastomosis in the long term.

The stated technical result is achieved by the fact that in the method of strengthening the proximal anastomosis of a synthetic prosthesis with the abdominal and thoracic aorta with a telescopic cuff, based on the formation of a proximal anastomosis of the aorta with a synthetic prosthesis using a telescopic cuff. The vascular prosthesis in the zone of formation of the proximal anastomosis is previously turned outward, thereby forming a telescopic cuff from the prosthesis (Figure 1), then the formation of the proximal anastomosis with a continuous twisted suture is started (Figure 2, 3), after the formation of the anastomosis, the telescopic cuff is expanded before the blood flow starts ( Figure 4) in such a way that the cuff closes the proximal anastomosis area, the blood flow is triggered, after the blood flow starts, the synthetic prosthesis expands independently, thereby strengthening the proximal anastomosis, if it is necessary to better position and optimize the telescopic cuff, it is partially reduced along the anterior wall with a coiled suture Prolene suture 5/0 on an atraumatic needle in the longitudinal direction (Figure 5).

The method is carried out as follows.

The operation begins with access to the aorta. The main stage of the operation - prosthetics of the aorta is performed according to the standard technique. Allocate the "neck" of the aneurysm. The aorta is compressed in the transverse direction in the region of the unchanged area proximal to the area of the forthcoming reconstruction. The aorta is transected in the transverse direction. The formation of a proximal aortic anastomosis with a synthetic prosthesis is started with a continuous twisted suture with a prolene thread No. 4 on an atraumatic needle No. 20. A telescopic cuff is preliminarily formed on a synthetic prosthesis, turning out the proximal part of the prosthesis. After the formation of the anastomosis, before starting the blood flow, the telescopic cuff is expanded in such a way that the cuff closes the proximal anastomosis zone. The blood flow is started. After the start of the blood flow, the synthetic prosthesis expands independently, thereby strengthening the proximal anastomosis. If it is necessary to better position and optimize the telescopic cuff, its partial reduction is performed by suturing it in the longitudinal direction along the front wall with a twisted suture with prolene thread No. 4 on an atraumatic needle No. 20. Then they begin to form the distal anastomosis of the synthetic prosthesis.

Example. Patient R., 64 years old, was admitted to the Department of Vascular Surgery No. 1 of the Clinic of Faculty Surgery of the Samara State Medical University Clinic on May 14, 2018 with complaints: a feeling of increased pulsation in the umbilical region, the presence of a pulsating formation in the abdomen. He considers himself ill for the last three years, when he began to notice a sensation of pulsation in the umbilical region. But I did not attach any importance to this. In the spring of 2018, ultrasound examination revealed an aneurysm of the abdominal aorta; computed tomography of the aorta was performed, the presence of an aneurysm of the abdominal aorta was confirmed. The absolute indications for surgical treatment were determined - prosthetics of the abdominal aorta. Hospitalized in OCX No. 1 of the farm for surgical treatment.

Concomitant pathology: ischemic heart disease. Stable exertional angina, FC II. cl. Arterial hypertension grade III, grade 3, risk 4. HI. Atherosclerosis of the aorta and its branches. Stenoses of the carotid arteries on both sides. COPD. Grade 1, risk B, moderate, no exacerbation. DN0.

Objectively: The general condition is satisfactory. Consciousness is clear, the position is active. The physique is hypersthenic, the skin is without rash, pale pink in color. Mucous membranes are moist, pink. No edema. The lymph nodes are not enlarged. Look friendly, OS = OD. Eye symptoms of thyrotoxicosis are negative. Speech is intelligible, swallowing is preserved. The rib cage is cylindrical. The movements of the chest are symmetrical. NPV 16 per minute at rest. On percussion - pulmonary tone. Auscultatory breathing was hard, no wheezing. Heart sounds are quiet, the rhythm is correct. Heart rate 86 per minute. HELL 135 and 80 mm Hg. on the left hand, 135 and 80 mm Hg on the right hand. The abdomen is rounded, not swollen, symmetrical, participates in the act of breathing, soft, painless on palpation. In the umbilical region, a pulsating formation is palpable, dense elastic consistency, painless on palpation, 80 × 100 mm in size. Symptoms of peritoneal irritation are negative in all parts of the abdomen. Peristalsis is uniform. According to the patient, the stool is regular. The liver does not protrude from the edge of the costal arch. The spleen is not palpable. The renal region was normal on examination and painless on palpation. The ureteral points are painless. Pasternatsky's symptom is negative on both sides. Difficulty urinating is not noted. Right n / a limb: pale pink, warm to the touch. Sensitivity and movement are fully preserved. Ripple in the projection of the femoral artery is preserved. The distal pulse is determined. Left n / limb: pale pink, warm to the touch. Sensitivity and movement are fully preserved. Ripple in the projection of the femoral artery is preserved. The distal pulse is determined.

According to computed tomography with contrast from 03/07/2018: in the infrarenal abdominal aorta, 2 cm below the level of the renal artery discharge, there is a fusiform aneurysm with a maximum transverse dimension of 83 mm with extension to the common iliac arteries.

After the examination, the clinical diagnosis was made:

The main one is an aneurysm of the infrarenal aorta with extension to the common iliac arteries.

Accompanying - ischemic heart disease. Stable exertional angina, FC II. cl. Arterial hypertension grade III, grade 3, risk 4. HI. Atherosclerosis of the aorta and its branches. Stenoses of the carotid arteries on both sides. COPD. Grade 1, risk B, moderate, no exacerbation. DN0.

After appropriate preoperative preparation, on May 16, 2018, the operation was performed - laparotomy, bifurcation aorto-iliac prosthetics, reduction of aneurysm.

Anesthesia - combined anesthesia.

Duration of surgery - 250 minutes

The volume of intraoperative blood loss was 400 ml.

Description of the operation: Midline laparotomy. The posterior peritoneum is dissected. The aorta was isolated. The aorta is markedly atherosclerotic. At the level of the renal arteries with a diameter of about 2 cm; 2 cm below the renal arteries, a spindle-shaped aortic aneurysm up to 80 mm with extension to the common iliac arteries. The NBA is occluded. Clamp on the aorta 1 cm below the renal arteries, clamped the iliac arteries in the initial sections. The aneurysm was dissected in the longitudinal direction, the aneurysmal cup was removed, with old and fresh blood clots. The aneurysmal sac was reduced according to the clinic's method. Satisfactory pulsating antegrade blood flow from the aorta. Formed a proximal anastomosis between the aorta and the main jaws of the Uni-Graft K DV prosthesis "16 × 8 × 8" in the "end-to-end" type with a telescopic cuff with 4/0 prolene suture. The telescopic cuff is straightened, positioned, somewhat reduced in the longitudinal direction with a 5/0 prolene suture. The clamp was transferred from the aorta to the small branches of the prosthesis. The iliac arteries are diffusely atherosclerotic. Distal end-to-end anastomoses were alternately formed between the branches of the prosthesis and the OPA above the fork on both sides, with a 6/0 prolene thread. After starting the blood flow, there is a distinct pulsation of the arteries and the prosthesis above and below the reconstruction zone. Revision for hemostasis and foreign bodies. The revision of the abdominal organs - no damage. The large and small intestines are viable, peristaltic. Blockade of the mesenteric root and mesocolon 80 ml 0.25% novocaine solution. Suturing the postoperative wound in layers. Aseptic dressing.

After surgery, pulsation on the branches of the prosthesis. The pulse is palpated on the ZBBA on both sides.

The postoperative period was unremarkable. The stitches have been removed. Discharged from the hospital on the 10th day.

This method of strengthening the proximal anastomosis of a synthetic prosthesis with the aorta has been used in more than 300 patients and has been used in the Department of Vascular Surgery of the Clinic of Faculty Surgery of the Samara State Medical University Clinics for more than 30 years. During the entire observation period of patients in the long-term period after the operation, there were no cases of proximal anastomosis aneurysm formation.

Thus, the proposed method is effective in the surgical treatment of patients with aneurysms of the thoracic and abdominal aorta, as well as obliterating diseases of the aorta and improves the results of treatment of this category of patients.

Claims (1)

A method of strengthening the proximal anastomosis of a synthetic prosthesis with the abdominal and thoracic aorta with a telescopic cuff, including preliminary outward turning of the vascular prosthesis in the zone of formation of the proximal anastomosis, forming a cuff from the prosthesis, then proceeding to the formation of the proximal anastomosis with a continuous coiled suture, after the formation of the anastomosis, the production is performed before in such a way that the cuff closes the proximal anastomosis zone, the blood flow is triggered, after the blood flow is triggered, the synthetic prosthesis spontaneously expands, then the cuff is reduced along the anterior wall with a twisted suture with 5/0 prolene thread on an atraumatic needle in the longitudinal direction.

Images