RU2789746C1 - Method for surgical treatment of false aneurysm of the femoral artery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to vascular surgery and transplantation. Block the blood flow in the false aneurysm. To do this, a balloon catheter is inserted into the femoral artery on the side of the false aneurysm and placed in the area of the neck of the false aneurysm. The balloon is inflated to cover the lumen of the femoral artery at the level of the neck of the false aneurysm, at least 20 mm proximal and distal to the neck of the false aneurysm. After that, the skin and subcutaneous adipose tissue are dissected. The length of the incision corresponds to the length of the false aneurysm. The aneurysmal sac is opened. Then the defect of the femoral artery in the area of the neck of the false aneurysm is sutured with a continuous two-row blanket suture with the capture of the outer and middle shells of the femoral artery. Then the balloon is deflated and the catheter is removed from the femoral artery. The aneurysmal sac is excised. The resulting cavity and wound are sutured in layers.

EFFECT: method provides reduction or complete absence of blood loss during the operation, reduction of mortality, reduction of intervention trauma, and also provides prevention of infectious complications by minimizing operative access to a false aneurysm of the femoral artery.

1 cl, 1 dwg, 1 ex

Description

SUBSTANCE: invention relates to medicine, namely to vascular surgery and transplantation, and can be used to treat developed complications after the use of peripheral extracorporeal membrane oxygenation.

Heart transplantation is the only radical and generally accepted way to treat patients with end-stage heart failure. For many years, a little more than 5,500 such operations per year have been performed in the world, however, the need for their implementation is much higher. More than 40% of heart transplant recipients, due to the extreme severity of their condition, require the use of short-term mechanical circulatory support. The gold standard for heart pumping replacement in the short term is extracorporeal membrane oxygenation (ECMO).

The method has established itself as a highly effective way to maintain systemic hemodynamics at the stage of waiting for a donor organ. One of the possible complications of its use is the development of vascular complications during ECMO by peripheral (femoral) access.

A false femoral artery aneurysm (LAFA) is a rupture of all three layers of the arterial wall. Under the influence of stable blood pressure, the blood cuts through the tissues around the damaged artery and forms a sac that communicates with the lumen of the artery. Post-catheterization LABA is one of the most common vascular complications after cardiac surgery and endovascular procedures. After implantation of ECMO LABA cannulas, up to 14% of cases occur. The need to use a large arterial cannula leads to the formation of clinically significant LAAA with the threat of rupture and sudden bleeding. The development of approaches to the treatment of this pathology is critical for improving the long-term survival of heart transplant recipients.

To date, in the treatment of LAAA after implantation of ECMO cannulas, the surgical method is universally applicable, which consists in accessing the proximal and distal parts of the artery, taking the artery on holders, clamping them, opening a false aneurysm, and evacuating the hematoma. The puncture site is determined and one or two sutures are applied transversely with a synthetic non-absorbable thread to avoid narrowing. If the vessel is severely damaged or affected, arteriotomy and angioplasty with an autovein or xenoperiard patch may be required [Morgan, Robert; Belli, Anna-Maria (2003). Current Treatment Methods for Postcatheterization Pseudoaneurysms, 14(6), 697-710].

The disadvantage of this method in the context of the development of false aneurysms using peripheral ECMO is the complexity of surgical access to the upper and lower parts of the femoral artery, associated with the risk of significant blood loss due to the preservation of arterial blood flow in the aneurysm, as well as the need to perform an extended incision to avoid entering the wound cavity. with active circulation. Consideration should be given to the need for surgical excision of false aneurysms of the femoral artery in heart recipients in view of the high risk of infection of the cavity against the background of intensive immunosuppressive therapy in the early stages after transplantation.

At the same time, when performing an operation from a skin incision that significantly exceeds the size of the aneurysm, complications associated with prolonged wound healing against the background of ongoing immunosuppressive therapy, including antiproliferative drugs, are often noted.

We have set the task of improving the surgical technique for the treatment of LAAA in order to minimize intraoperative risks and increase the effectiveness of the intervention.

Medico-technical result achieved in the implementation of the invention is

- reduction or complete absence of blood loss during the operation and, as a result of this, a decrease in mortality;

- reducing the trauma of the intervention, preventing infectious complications by minimizing the operational access to the LABA.

EFFECT: method allows to perform the operation from the smallest possible incision, corresponding only to the size of the aneurysm itself, since there is no need to isolate and clamp the femoral artery and its large branches significantly above and below the site of the false aneurysm. The latter is also an important factor in heart transplant recipients receiving immunosuppressive therapy, which reduces the repair capacity of tissues in the postoperative period.

The essence of the invention is as follows.

For surgical treatment of a false aneurysm of the femoral artery that developed after implantation and subsequent removal of the cannula for peripheral extracorporeal membrane oxygenation, the defect of the femoral artery is sutured. In this case, the blood flow in the false aneurysm is first blocked. Why a balloon catheter is inserted into the femoral artery on the side of the false aneurysm, it is installed in the area of the neck of the false aneurysm. The balloon is inflated to cover the lumen of the femoral artery at the level of the neck of the false aneurysm and at least 20 mm proximal and distal to the neck of the false aneurysm. After that, the skin and subcutaneous adipose tissue are dissected. The length of the incision corresponds to the length of the false aneurysm. The aneurysmal sac is opened. Then the defect of the femoral artery in the area of the neck of the false aneurysm is sutured with a continuous two-row blanket suture with the capture of the outer and middle shells of the femoral artery. Then the balloon is deflated and the catheter is removed from the femoral artery. The aneurysmal sac is excised. The resulting cavity and wound are sutured in layers.

The method is carried out as follows:

The patient performs a puncture of the contralateral femoral artery. The contralateral introducer is inserted into the iliac artery. The diameter of the balloon catheter is selected in accordance with the diameter of the femoral artery in the area of the aneurysm, its length is selected with the calculation of the occlusion of the lumen of the femoral artery in the neck of the aneurysm with a "margin" of occlusion in the proximal and distal directions of 20 mm, that is, ensuring the occlusion of the lumen of the femoral artery as at the level neck of the false aneurysm and at least 20 mm proximal and distal to the neck of the false aneurysm. The balloon catheter under X-ray control is inflated directly at the level of the neck of the aneurysm, thereby blocking the blood flow inside it. A control angiography is performed - there is no blood flow in the aneurysm with the correct installation of the balloon catheter. Further, in the femoral triangle, from the side of the existing false aneurysm of the femoral artery, the skin is cut with a projection incision for a length corresponding to the size of the false aneurysm, that is, the length of the soft tissue incision is limited by the size of the false aneurysm. Then the aneurysmal sac is opened. Due to the complete occlusion of the blood flow by the balloon catheter, there is no active blood flow in the aneurysm cavity. Evacuate the contents of the aneurysmal sac. The defect of the anterior wall of the femoral artery in the cervical area is sutured with a continuous two-row twist suture with the capture of the adventitia (outer sheath) and media (middle sheath), which makes it possible to exclude a violation of the integrity of the balloon catheter located in the lumen of the artery at the level of suturing. The balloon is deflated, blood flow is started. The pulsation of the femoral artery is assessed. The aneurysmal sac is excised. The remaining cavity and wound are sutured in layers. With this variant of the surgical technique, blood loss during the operation is minimized or completely absent.

Thus, a shortening of the operation time and a significant reduction or complete absence of blood loss is achieved with the complete removal of a false aneurysm of the femoral artery, and the operation is also performed from the smallest possible incision corresponding to the size of the aneurysm, which cannot be achieved using previously known surgical techniques.

Clinical example.

Patient P., aged 48, is considered as a clinical example. Diagnosis before surgery: Basic: 172.4 False aneurysm of the femoral artery on the right. Z94.1 Presence of a transplanted heart. Operations: implantation of an extracorporeal membrane oxygenation system. Orthotopic heart transplant. Concomitant diseases: 170.8 Atherosclerotic lesions of the brachiocephalic arteries, without hemodynamic disturbance. 170.2 Atherosclerotic changes in the arteries of the lower extremities, without hemodynamic disturbances.

A heart transplant operation was performed against the background of peripheral ECMO. After removal of the ECMO system, according to color duplex scanning of the arteries of the lower extremities: on the right - in the projection of the bifurcation of the femoral artery, a false aneurysm 4.5x3.2 cm in size with active blood flow, partially thrombosed, neck diameter 0.55 cm, is located along the anterior wall; On the left, no pathology was detected. According to computed tomography of the arteries of the lower extremities: on the right, somewhat distal to the mouth of the femoral artery, a false aneurysm with a diameter of 32 mm, a neck with a diameter of 6.7 mm, is visualized. Extravasation of the drug beyond the aneurysm is not recorded. The drawing shows a CT picture of a large false aneurysm of the right femoral artery in a patient who underwent heart transplant against the background of peripheral ECMO in two projections.

Performed the operation of resection of a false aneurysm of the femoral artery on the right in accordance with the proposed method. Progress of the operation: A puncture of the left femoral artery was performed. A 6F contralateral sheath is placed in the left iliac artery. The balloon catheter was used to dilate the balloon with a pressure of 6 atmospheres directly under the aneurysm, ensuring the occlusion of the lumen of the right femoral artery at the level of the neck of the false aneurysm and 20 mm proximal and distal to the neck of the false aneurysm. Control angiography revealed no blood flow in the right common femoral artery. In the right femoral triangle, there is a swelling of a densely elastic consistency, pulsating on palpation. A projection incision in the right femoral triangle for a length of 4.5 cm, not exceeding the size of the aneurysm, dissected the skin, opened the aneurysmal sac. There is no active blood flow in the aneurysm cavity. The defect of the anterior wall of the femoral artery is sutured with a continuous two-row twist suture with Prolene 6-0 thread. The balloon was deflated, after the start of blood flow, a good pulsation of the femoral artery was noted. There are no signs of bleeding. Seams are wealthy. A false aneurysm was excised with the help of an electrocoagulator, the remaining cavity and the wound were sutured in layers, leaving a drain brought out through the counter-opening. Aseptic sticker. There was no blood loss during the operation. The duration of the operation was 1 hour 35 minutes.

The patient was transferred to the cardiac surgery department 2 hours after the operation. According to the ultrasound examination of the vessels of the lower extremities, the blood flow through the arteries of the thigh is main, satisfactory. The postoperative wound healed by primary intention. The patient was discharged from the hospital on the 7th day after the operation in a satisfactory condition.

This operation clearly demonstrates the possibility of performing resection of a false hip aneurysm in a safe way with virtually no blood loss, which inevitably accompanies operations of this kind using the standard technique. This operation was performed from a skin incision 4.5 cm long, not exceeding the size of the aneurysm, which is an extremely important factor in successful wound healing in the postoperative period against the background of ongoing immunosuppressive therapy.

The proposed method was used in 7 recipients of a transplanted heart. In all operated patients, the resection of the femoral artery aneurysm was completed without complications; according to the results of ultrasound examination of the vessels, the main blood flow with satisfactory velocity characteristics was located in the postoperative period.

Claims (1)

A method of surgical treatment of a false aneurysm of the femoral artery that has developed after implantation and subsequent removal of a cannula for peripheral extracorporeal membrane oxygenation, including suturing the defect of the femoral artery, characterized in that the blood flow in the false aneurysm is first blocked, for which a balloon catheter is inserted into the femoral artery on the side of the false aneurysm , install it in the area of the neck of the false aneurysm and inflate the balloon, providing overlap of the lumen of the femoral artery at the level of the neck of the false aneurysm and at least 20 mm proximal and distal to the neck of the false aneurysm; then dissect the skin and subcutaneous fatty tissue, while the length of the incision corresponds to the length of the false aneurysm, and open the aneurysmal sac; then the defect of the femoral artery in the area of the neck of the false aneurysm is sutured with a continuous two-row blanket suture with the capture of the outer and middle membranes of the femoral artery; after which the balloon is deflated and the catheter is removed from the femoral artery, the aneurysmal sac is excised, the resulting cavity and the wound are sutured in layers.

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