RU2745727C1 - Method of formation of bifurcation autovenous conduit - Google Patents

Abstract

FIELD: medicine; vascular surgery.

SUBSTANCE: conduit is formed between the internal jugular vein, which is the main branch of the conduit, and the two superficial femoral veins – the right and left branches of the conduit, respectively. At the same time, at the first stage, the superficial femoral veins are stitched together. The first polypropylene thread is used to form an anastomosis, piercing from the inside of the vein, and a wrap-around seam is applied, starting from the intended lower edge in the direction of the upper edge of the conduit with a needle pricked out inside the vein. A continuous wrap-around seam in the form of a second row is applied with the second polypropylene thread in the opposite direction, piercing from the outside into the vein, crossing the ties of the first thread with a needle pricked the inside out of the vein. Then, the second stage of the formation of the conduit is performed: the internal jugular vein is stitched with the previously stitched superficial femoral veins. To do this, a continuous wrap-around seam is applied with the ends of the first and second threads, respectively, towards each other; the femoral veins are sewn alternately with the internal jugular vein. The final formation of the anastomosis is performed by tightening and binding the ends of the threads together.

EFFECT: method allows obtaining an anatomically correctly formed and the longest bifurcation autovenous conduit, avoid a shortage of blood supply to the limbs, and stop the infectious process, thereby preventing septic complications and relapse of infection.

1 cl, 2 tbl, 10 dwg, 3 ex

Description

The proposed invention relates to medicine, namely to vascular surgery and can be used to treat patients with purulent-septic complications after surgical treatment with implantation of a synthetic bifurcated vascular prosthesis in the aortic position.

Vascular infection has been and remains one of the most difficult and most dangerous problems that a vascular surgeon can face. Infection of aorto-femoral bifurcation prostheses, after operations on the abdominal aorta, develops in 4.6% of cases [Gulaev, O.G. Tactics of surgical treatment of patients with purulent-septic complications after reconstructive operations on the abdominal aorta: author. dis. ... Cand. honey. sciences. - M., 2013. - 26 p.]. Conservative treatment based on specific antibiotic therapy is ineffective, since complete removal of the infected vascular graft is required to eradicate the infection. To restore the blood supply to the extremities, it is necessary to perform either extra-anatomical shunting, which is also accompanied by the implantation of a synthetic prosthesis, or replacement of the infected conduit to eliminate the risk of recurrence of the infection. Complications caused by wound infection in the postoperative period are the cause of amputation of the lower extremities in 13-75% of cases and are accompanied by a high mortality rate - 1-75%, reaching 100% with prosthetic sepsis [Kearney R.A., Non-valvular infections of the cardiovascular system. Ann Intern Med. - 1994., Vol. 121 (3). - P. 219-230].

The operation of extra-anatomical axillary-femoral shunting was taken as an analogue.

Axillary-femoral shunting is performed on the side of the greatest lesion of the limb. An 8 cm long incision of the skin, subcutaneous tissue and superficial fascia is made in parallel at a distance of one transverse finger width below the clavicle in its middle third.

The pectoral fascia is dissected and the fibers of the clavicular part of the pectoralis major muscle are separated, then a retractor is placed there. The deep clavicular-thoracic fascia is dissected, under which the first section of the axillary artery, the vein of the same name and the brachial plexus are located. The canal for the shunt is formed using a tunnelizer without intermediate skin incisions. Then the prosthesis is carried out from the thigh in a pre-formed canal and the branch of the prosthesis is brought out to the axillary artery. Anastomoses are applied "the end of the prosthesis to the side of the artery" with a continuous twisted suture with polypropylene suture 5.0 using standard techniques [Guide to vascular surgery, Yu.V. Belov, 2011, pp. 117-119]. This method of revascularization leads to unsatisfactory results in many patients, while the mortality rate is from 20 to 25%, and the frequency of amputations is from 10 to 15% [Nevelstin A., Lacroix X., Sui R. In situ autoreconstruction in aortic prosthesis infection : the meaning of deep veins of the lower extremities. Angiology and Vascular Surgery, 1997, No. 3, p. 98-106].

For the closest analogue adopted the method of aorto-femoral reprosthetics using deep veins of the lower extremities, after removal of the infected synthetic bifurcation prosthesis [Nevelstin A., Lacroix X., Sui R. In situ autoreconstruction in aortic prostheses infection: the value of deep veins of the lower extremities. Angiology and vascular surgery, 1997, No. 3, S. 98-106]. An autovenous conduit from the superficial femoral veins is used as a shunting material. Superficial femoral veins are isolated from linear incisions along the medial surface of the thigh, distal to the mouth of the deep femoral vein and to the level of the popliteal vein, depending on the required length of the conduit. After removal of the infected synthetic vascular prosthesis, the arteries are reshunted by implantation of autoveins in the bed of the removed synthetic prosthesis. In this case, for bilateral reconstructions, the proper femoral veins of both lower extremities are used.

The disadvantages of these methods are:

1. The use of a synthetic prosthesis, in overwhelming cases, leads to repeated suppuration, the development of a severe septic condition and death of the patient;

2. The subcutaneous location of the vascular graft is non-anatomical and unsafe;

3. The high incidence of thrombosis of extra-anatomical shunts due to their great length;

4. Formation of an autovenous bifurcation conduit using two superficial femoral veins, cannot provide sufficient length with high aortic prosthetics, does not have an anatomical structure due to the absence of the main branch of the conduit;

5. The use of common femoral veins, with insufficient length, leads to chronic venous insufficiency of the lower extremities;

6. Lack of a specific method of forming the anastomosis of the autovenous conduit.

The objective of the invention is:

1. To obtain the required length of the conduit for prosthetics of the abdominal aorta at any level;

2. Reduce the risk of anastomotic leakage of the formed autovenous bifurcation conduit;

3. Introduce the optimal method for the formation of an autovenous bifurcation conduit that meets all the requirements of surgical treatment;

4. Stop the infectious process in the body, eliminate the risk of recurrence of the infection, reduce mortality;

5. Eliminate the risks of thrombosis and preserve the function of the lower extremities.

The essence of the invention is the formation of an autovenous conduit with two atraumatic polypropylene sutures 5.0, alternately, continuously, twisted sutures starting from the intended lower edge towards the upper edge of the conduit, first in one direction, then with a second thread in the opposite direction, stitching both superficial femoral veins together, obtaining the right and left branches of the conduit being formed, after which the internal jugular vein is sewn to the two branches obtained with the withdrawn ends of the threads, by alternately continuing continuous seams in opposite directions and connecting the threads with a knot.

The technical result when using the invention was achieved by using the proposed method of forming an anastomosis, in which an autovenous non-furcation is created between the internal jugular vein, which is the main branch of the conduit, and two superficial femoral veins - respectively, the right and left branches of the conduit, the resulting length allows you to perform the operation on any the level of the abdominal aorta. The use of two threads and a continuous suture ensures the necessary tightness and non-furcation strength. Tying two different threads together, at the end of the conduit formation, avoids "corrugation" of the anastomosis and maintains the maximum diameter of the veins used, which leads to a more laminar blood flow and a decrease in the risk of thrombosis.

The method was tested in the State Budgetary Healthcare Institution “Research Institute-Regional Clinical Hospital No. 1 named after Professor S.V. Ochapovsky "of the Ministry of Health of the Krasnodar Territory, in a clinical setting for 6 patients.

Data on patients who underwent surgery according to the proposed method are shown in table No. 1.

The table shows that in all patients operated on using the proposed method, septic complications, recurrence of infection, thrombosis and conduit failure were absent, in all cases, the limbs were preserved.

Data on patients who underwent surgery: extra-anatomical bypass grafting, resection with replacement of the branch of the prosthesis are shown in Table 2.

The patients indicated in Table No. 2 were operated on with the use of a synthetic prosthesis, in the postoperative period they had complications: in the form of a recurrence of the prosthesis infection in 8 patients, of whom 5 had acute shunt thrombosis, this led to decompensation of the arterial blood supply and amputation limbs for health reasons, and 3 patients were reoperated using the proposed method.

For a better understanding, the method of forming an autovenous bifurcation conduit is shown in the appendix in FIG. 1-10. Figure 1-3 stitching the proximal portions of the superficial femoral veins together; 4-6 suturing two superficial femoral veins with the internal jugular vein, FIG. 7 is an intraoperative view of the formed autovenous bifurcation conduit, FIG. 8 - implanted conduit, where 1 - right superficial femoral vein, 2- left superficial femoral vein, 3- first thread, 4- second thread, 5- internal jugular vein. FIG. 9-10 show the results of computed tomography three years after the operation.

The method is carried out as follows: the patient is under endotracheal anesthesia, the position is on the back with a roller placed under the lumbar region. Incisions are made in the projection of the superficial femoral veins on the right and left. Along the entire length, from the confluence with the deep femoral vein to the level of the knee joint, the superficial femoral veins are isolated, the tributaries are ligated, the veins are explanted, the proximal and distal stumps are ligated twice with suturing.

On one side, an incision is made in the projection of the jugular vein, along the anterior edge of the sternocleidomastoid muscle, from the jugular notch in the cranial direction to the angle of the lower jaw. The internal jugular vein is isolated at the maximum extent, the tributaries are ligated, taken with clamps, cut off, the vein stumps are ligated twice with suturing.

Formation of the autovenous bifurcation conduit of FIG. 1-6 between the jugular (5) and two superficial femoral veins (1, 2), can be conditionally divided into two stages. The first stage: stitching the superficial femoral veins (1, 2) together. The assistant holds the two superficial femoral veins with two curved forceps, parallel to each other from the inside. With the first polypropylene suture 5.0 (3), the surgeon begins to form the anastomosis of FIG. 1, sticking in from the inside, veins 1, departing from the cut of the vein 0.2 mm., The continuous twisted suture is continued towards the opposite edge with a needle punctured inside the vein 2. The second polypropylene suture 5.0 (4) in the opposite direction of FIG. 2, symmetrically retreating from the edges of the vein, sticking from the outside to the inside of the vein 2, a continuous twisted suture is made in the form of a second row, crossing the ties of the first thread (3), with an edge puncture from the inside to the outside of the vein 1. An illustration of the technical execution of the above stage is shown in Fig. 3.

Then the second stage of conduit formation is performed: suturing of the internal jugular vein (5) with the previously sutured superficial femoral veins (1, 2). The ends of the first (3) and second strands (4), FIG. 4 and FIG. 5, respectively, towards each other, continuously continuing the twisting suture, alternately veins 1 and 2 are sutured with the internal jugular vein (5). The final formation of the anastomosis is carried out by simultaneously tightening and tying the ends of the threads together, FIG. 6, under conditions of a conduit filled with saline, with moderate pressure injected through a cannulated needle in a vein (5). Check the tightness of FIG. 7.

From previously performed incisions on the lower extremities, sequentially, fistulous passages are excised, an infected synthetic prosthesis, deep, superficial femoral arteries are isolated. The arteries and the prosthesis are taken on the holders.

A midline laparotomy is performed, a festering synthetic vascular prosthesis is isolated. The aorta and femoral vessels are isolated throughout, in the proximal and distal directions, respectively, outside the anastomoses. 2500 U of heparin is injected intravenously. The aorta and femoral arteries are clamped. Cut off and complete removal of the infected prosthesis and paraprosthetic tissues with obligatory bacterial inoculation. The remaining bed is treated with antiseptic solutions. Then, an anastomosis is formed between the aorta and the main branch of the bifurcation autovenous conduit with a 4.0 monofilament thread.

Through the created tunnels along the iliac vessels, or in the bed of the removed infected prosthesis, branches of the autovenous conduit are passed in the distal direction to the right and left. Alternately, anastomoses are formed between the branches of the autovenous conduit and the femoral arteries, either end-to-end or end-to-side with 5.0 polypropylene suture. They start the blood flow, carry out hemostasis. Conduit functions photo 2 application.

The retroperitoneal space and abdominal cavity are drained with single-lumen polyvinyl chloride drains. Wounds on the thighs are drained according to Redon. Wounds are sutured in layers.

Example 1. Patient MSA, 62 years old, with a diagnosis of Atherosclerosis. Occlusion of both external iliac arteries. KHAN III Art. Condition after aorto-femoral bifurcation prosthetics. Late suppuration of the branch of a bifurcated synthetic prosthesis. The operation “Removal of an infected prosthesis. Repeated aorto-femoral bifurcation prosthetics with an autovenous conduit from the left internal jugular vein and superficial femoral veins of both lower extremities ", which was carried out as follows: the patient was under endotracheal anesthesia, the patient was placed on his back with a roller placed under the lumbar region. A midline laparotomy was performed, a suppurative bifurcation synthetic vascular prosthesis was isolated. In parallel, two superficial femoral and jugular veins were harvested, and a bifurcational autovenous conduit was formed using the proposed method. After intravenous injection of 2500 U of heparin, the aorta was clamped below the orifices of the renal arteries, aorthotomy was performed, the prosthesis was cut off and thrombotic masses were removed, then anastomoses were formed alternately between the aorta and the main branch of the bifurcation autovenous conduit with a monofilament prosthesis 4.0 between the branches of the autovenous conduit and the femoral arteries in an end-to-end manner with 5.0 polypropylene suture. Starting blood flow, hemostasis. The retroperitoneal space and abdominal cavity were drained with single-lumen polyvinyl chloride drains. The wounds on the thighs were drained according to Redon. The wounds were sutured in layers.

The postoperative period was uneventful. The patient was in the conditions of the department of anesthesiology and intensive care for 7 days. Pulsation in the projection of the main arteries of the lower extremities is determined on both sides at all levels. The patient had no septic complications in the postoperative period.

When re-examining one month after the operation, the patient's condition is satisfactory, the consciousness is clear. BP 137/82 mm Hg, pulse 78, NPV 16 per minute. Pulsation in the projection of the main arteries of the lower extremities is determined on both sides at all levels. The patient has no septic complications.

Example 2. Patient BSF, 56 years old, with a diagnosis of Atherosclerosis. Occlusion of the superficial femoral artery, posterior tibial artery of the right lower limb. Occlusion of the superficial femoral artery of the left lower extremity. Condition after aorto-femoral bifurcation prosthetics 06/02/2017 KAN PB. Purulent fistula of the anterior abdominal wall, infection of the prosthesis. The operation was carried out as follows: the patient was under endotracheal anesthesia, the position of the patient on his back with a roller placed under the lumbar region. A midline laparotomy was performed, a suppurative bifurcation synthetic vascular prosthesis was isolated. In parallel, two superficial femoral and jugular veins were harvested, and a bifurcational autovenous conduit was formed using the proposed method. After the introduction of 2500 U of heparin, the aorta was clamped below the orifices of the renal arteries, the prosthesis was cut off, its complete excision was performed along with the infected paraprosthetic tissues. The prosthesis bed was treated with antiseptic solutions. First of all, an anastomosis was formed between the aorta and the main branch of the bifurcated autovenous conduit with a 4.0 monofilament suture, and then, after the branch of the autovenous conduit was inserted into the femoral wounds, anastomoses were alternately performed with the femoral arteries in the "end-to-end" polypropylene thread with 5.0 polypropylene suture. Starting blood flow, hemostasis. After preliminary marking with Brilliant Green solution, the fistula of the anterior abdominal wall was excised within healthy tissues. The retroperitoneal space and abdominal cavity were drained with single-lumen polyvinyl chloride drains. The wounds on the thighs were drained according to Redon. The wounds were sutured in layers.

Example 3. Patient K.I.I., 60 years old, with a diagnosis of Atherosclerosis. Occlusion of the abdominal aorta, both common iliac arteries, external iliac arteries, internal iliac arteries. KHAN 2B. Art. both lower limbs. Condition after aorto-femoral bifurcation bypass from 04/05/17, suppuration of the right branch of the prosthesis, infection of the prosthesis. The operation was carried out as follows: the patient was under endotracheal anesthesia, the position of the patient on his back with a roller placed under the lumbar region. After the Brilliant Green solution was injected into the fistulous tract, a median laparotomy was performed, and two approaches were performed in the projection of the femoral vessels. Fistulous passages were excised, a suppurative bifurcation synthetic vascular prosthesis was isolated. In parallel, two superficial femoral and jugular veins were harvested, and a bifurcational autovenous conduit was formed using the proposed method. After the introduction of 2500 U of heparin, the aorta was clamped below the orifices of the renal arteries, the prosthesis was cut off, its complete excision was performed along with the infected paraprosthetic tissues. The prosthesis bed was treated with antiseptic solutions. First of all, an anastomosis was formed between the aorta and the main branch of the bifurcated autovenous conduit with a 4.0 monofilament suture, and then, after the branch of the autovenous conduit was inserted into the femoral wounds, anastomoses were alternately performed with the femoral arteries in the "end-to-end" polypropylene thread with 5.0 polypropylene suture. Starting blood flow, hemostasis. The retroperitoneal space and abdominal cavity were drained with single-lumen polyvinyl chloride drains. The wounds on the thighs were drained according to Redon. The wounds were sutured in layers.

Patients P.S.A. 65 p., I.N.G., 51, S.F.F. 53, the operation was carried out according to the above method.

At repeated examinations, 6 months and three years after the operation, the patient's condition is satisfactory, the blood supply to the extremities is preserved, and there is no arterial insufficiency. Pulsation in the projection of the femoral arteries is determined on both sides, systolic murmur is not heard. Control X-ray contrast methods of diagnostics were carried out, according to the results of which no leakage and aneurysm of the anastomoses were detected, 3D-reconstruction, three years after the operation, are presented in the appendix in photo 3-4.

Claims (1)

A method of forming a bifurcation conduit, characterized in that the conduit is formed between the internal jugular vein, which is the main branch of the conduit, and two superficial femoral veins - the right and left branches of the conduit, respectively, while at the first stage the superficial femoral veins are stitched together with the first polypropylene thread an anastomosis is formed by injecting from the inside of the vein; a twisting suture is applied starting from the intended lower edge towards the upper edge of the conduit with a needle punctured inside the vein; with a second polypropylene thread in the opposite direction, sticking from the outside to the inside of the vein, impose a continuous twisting suture in the form of a second row, crossing the ties of the first thread with a puncture from the inside to the outside of the vein; then the second stage of conduit formation is performed: the internal jugular vein is sutured with the previously sutured superficial femoral veins, for this, the ends of the first and second threads, respectively, towards each other, a continuous twisting suture is applied, alternately the femoral veins are sutured with the internal jugular vein, the final formation of the anastomosis is performed by tightening and tying the ends of the threads together.

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