RU2763259C2 - Modified method for taking auto-vein by “no-touch” methodology - Google Patents

Abstract

FIELD: medicine; cardiovascular surgery.

SUBSTANCE: large subcutaneous vein is isolated in a flap of soft tissues along its entire length without crossing a vein trunk. Then, it is removed from a wound cavity to the skin surface of the lower limb and covered with moistened napkins with a 2% papaverine solution. Subcutaneous adipose tissue is stitched with a continuous winding suture to the entire depth, leaving channels with a diameter of 30 mm at the exit of distal and entrance of proximal parts of the auto-vein trunk in a subcutaneous fat layer. Then, skin edges of the wound are immediately stitched together with a continuous intradermal suture, leaving unstitched areas 30 mm long at the exit and entrance points of the auto-vein trunk in the subcutaneous fat layer. Thus, auto-vein continues to be perfused with blood before anastomosing with coronary arteries, without hydraulic dilatations. As soon as the auto-vein is removed from the wound, skin edges left 30 mm unstitched are stitched with a continuous suture.

EFFECT: method improves the healing of the postoperative wound of the lower limb and improves intraoperative local hemostasis.

1 cl, 1 dwg

Description

The method relates to medicine, namely to cardiovascular surgery, and can be used at the stage of sampling the great saphenous vein in order to optimize intraoperative local hemostasis and improve the healing of a postoperative wound of the lower limb.

The well-known method of harvesting the great saphenous vein Souza using the “No-touch” technique for coronary bypass grafting is a priority in 2019 [1], since numerous studies have demonstrated better short- and medium-term graft patency and less intimal hyperplasia using this technique compared to the traditional harvesting method autoveins [2, 3].

It is known that postoperative wound complications on the lower extremities when using the "No-touch" technique occur more often than when using the traditional skeletonized technique, due to its traumatic nature in relation to soft tissues [4].

However, when using the "No-touch" technique, intraoperative blood loss from the open wound of the lower limb after heparinization is observed. In turn, the simultaneous obtaining of a durable autovenous conduit using the “No-touch” technique with adequate further healing of a postoperative wound of the lower limb is currently an urgent problem. The original “No-touch” technique proposed in 1996 by Souza is the isolation of the great saphenous vein in a soft tissue flap using electrocoagulation and the further location of the isolated conduit in the open wound of the lower limb until the moment of systemic heparinization and its extraction before direct anastomosis with the coronary arteries.

The disadvantage of this method is the long-term presence of the wound of the lower extremity in the open form, which, against the background of systemic heparinization carried out during surgery, provides additional blood loss, lymphorrhea and greater seeding of the microflora of the wound. The above drawback can further provoke complicated healing of the postoperative wound of the lower limb.

There is a known method of harvesting an autovein using the "No-touch" method using a device for the simultaneous supply of electrical bipolar and ultrasonic energy [5], which minimizes trauma to the surrounding soft tissues of the lower limb.

However, the isolated autovein is also in the open wound until the moment of direct anastomosis with the coronary arteries, which increases the risk of intraoperative blood loss and postoperative wound problems of the lower limb.

Closest to the described method is the method proposed by KimY.H. [6] and consisting in the collection of a large subcutaneous BeHbi "No-touch" through intermittent skin incisions and the additional introduction of a drainage tube into the wound with passive drainage for 2-3 days, which minimizes the size of the wound and improves outflow from the postoperative wound of the lower limb. The disadvantage of this method is also the presence, although smaller in size, but open wounds before the anastomosis of the autovein with the coronary arteries.

The invention is based on the task of creating a modified method for harvesting an autovein using the "No-touch" method.

The technical result that can be obtained by implementing the invention: the use of a modified method of sampling autoveins according to the "No-touch" method improves the healing of a postoperative wound of the lower limb and improves intraoperative local hemostasis.

This technical result is achieved by the fact that the proposed modified method of harvesting an autovein according to the "No-touch" method includes an isolated large saphenous vein in a soft tissue flap along its entire length without crossing the vein trunk in order to continue blood perfusion through it. Next, the wound is removed from the wound cavity to the surface of the skin of the lower limb and covered with moistened wipes with a 2% papaverine solution, then the subcutaneous fat is sutured with a continuous twisting suture to the entire depth, while channels with a diameter of 30 mm are left at the exit point of the distal and the entrance of the proximal sections of the autovein trunk into subcutaneous fat layer. Then, the skin edges of the wound are sutured with a continuous intradermal suture, leaving unsutured sections 30 mm long at the exit and entry points of the autovein trunk into the subcutaneous fat layer. At the same time, the autovein continues to be perfused with blood before and maximally after systemic heparinization before direct anastomosis with the coronary arteries, without hydraulic dilations. The sutured wound of the lower limb for the most part prevents excessive blood loss and seeding of the wound with microorganisms, while, as soon as the autovein is removed from the wound, the remaining 30 mm of unsutured skin edges are sutured with a continuous suture.

Brief description of the work.

To achieve the set task, namely, optimization of intraoperative local hemostasis and improvement of healing of the postoperative wound of the lower limb, the great saphenous vein is isolated in the soft tissue flap along its entire length without crossing the vein trunk (Fig. 1, No. 1) in order to continue blood perfusion through it . Then it is removed from the wound cavity to the surface of the skin of the lower limb and covered with moistened wipes with a 2% papaverine solution (Fig. 1, No. 5). The subcutaneous fat is sutured with a continuous twisting suture to the full depth, leaving channels with a diameter of 30 mm at the exit of the distal (Fig. 1, No. 2) and the entrance of the proximal (Fig. 1, No. 3) sections of the autovein trunk into the subcutaneous fat layer. Then, the skin edges of the wound are immediately sutured with a continuous intradermal suture (Fig. 1, No. 4) leaving unsutured sections 30 mm long at the exit and entry points of the autovein trunk into the subcutaneous fat layer. Thus, the autovein continues to be perfused with blood before and maximally after systemic heparinization before direct anastomosis with the coronary arteries, without hydraulic dilations. The sutured wound of the lower limb prevents excessive blood loss and seeding of the wound with microorganisms over its greater length; as soon as the autovein is removed from the wound, then the edges of the skin left 30 mm unsutured are subsequently sutured with a continuous suture.

The study of the modified method of autovein sampling using the "No-touch" method, obtained in clinical conditions, showed that this method can be used in cardiovascular surgery at the stage of sampling the great saphenous vein in order to optimize intraoperative local hemostasis and improve the healing of a postoperative wound of the lower limb. Thanks to the use of the proposed method, it was possible to improve the results of wound healing in the area of autovein isolation, i. reduce the number of wound complications and at the same time obtain a long-lasting autovenous conduit. A practical substantiation of the clinical efficacy and safety of autovenous extraction using the “No-touch” technique has been performed. Expanded knowledge about the effect of microflora on an open wound in the operating room and further healing of such a wound. It was found that the early suturing of open wounds of the lower extremity after the extraction of the autovein helps to reduce the frequency of wound healing disorders with simultaneous preservation of high short- and medium-term patency and less hyperplasia of the graft intima. Based on the data obtained, in order to optimize the results of autovein isolation, a modification of the “No-touch” technique was proposed. It is supposed to disseminate effective practices of cardiovascular surgery and determine the prospects for further development of various areas in the field of cardiovascular surgery.

Sources of information:

1. NeumannF.-J., Sousa-UvaM., AhlssonA. etal. (2018) 2018 ESC/EACTS Guidelinesonmyocardialrevascularization. Eur. Heart J. (00, 1-96 doi: 10.1093/eurheartj/ehy394).

2 Souza DS, Bomfim V, Skoglund H, Dashwood MR, Borowiec JW, Bodin L, et al. High early patency of saphenous vein graft for coronary artery bypass harvested with surrounding tissue, Ann ThoracSurg, 2001, vol. 71 (pg. 797-800).

3 Souza DS, Johansson B, Bojo L, Karlsson R, Geijer H, Filbey D, et al. Harvesting the saphenous vein with surrounding tissue for CABG provides long-term graft patency comparable to the left internal thoracic artery: results of a randomized longitudinal trial, J ThoracCardiovascSurg, 2006, vol. 132 (pg. 373-8).

4 Verma S, Lovren F, Pan Y, Yanagawa B, Deb S, Karkhanis R et al. Pedicled no-touch saphenous vein graft harvest limits vascular smooth muscle cell activation: the PATENT saphenous vein graft study. Eur J CardiothoracSurg2014;45:717-25.

5. Ishizawa A, Hamasaki A, Uchida T, Sadahiro M. A novel harvesting technique for a no-touch saphenous vein graft using the THUNDERBEAT device. Multimed Man Cardiothorac Surg. 2018 Sep 17;2018. doi: 10.1510/mmcts.2018.051.

6. Kim YH, Oh HC, Choi JW, Hwang HY, Kim KB. No-touch saphenous vein harvesting may improve further the patency of saphenous vein composite grafts: early outcomes and 1-year angiographic results. Ann ThoracSurg2017; 103:1489-97 (prototype).

Claims (1)

A modified method of harvesting an autovein using the "No-touch" method, characterized in that the great saphenous vein is isolated in the soft tissue flap along its entire length without crossing the vein trunk, then the isolated great saphenous vein is removed from the wound cavity to the surface of the skin of the lower limb and covered with moistened with napkins of a 2% solution of papaverine, then the subcutaneous fat is sutured with a continuous twisting suture to the entire depth, while channels with a diameter of 30 mm are left at the exit point of the distal and proximal sections of the autovein trunk into the subcutaneous fat layer, then the skin edges of the wound are sutured with a continuous with an intradermal suture leaving unsutured sections of 30 mm in length at the exit and entry points of the autovein trunk into the subcutaneous fat layer, systemic heparinization is performed, anastomosis of the autovein with the coronary arteries is performed, without hydraulic dilations, while after removal of the autovein from the wound, the left 30 mm of unsutured skin edges are sutured with a continuous suture.

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