RU2793417C1 - Method for forming a proximal anastomosis in a dissecting aortic aneurysm with lower limb malperfusion syndrome - Google Patents

Abstract

FIELD: medicine; vascular surgery.

SUBSTANCE: longitudinal prosthesis in the area of the proximal anastomosis is performed. Transverse blanket sutures are applied to the area of prosthesis. The suture ties are not tightened and in the area of the middle of the tomy they are moved apart with a dissector. Aortotomy is performed with a scalpel through the extended ties. The ties in the region of the tomy of the prosthesis are tightened, distal anastomoses are formed.

EFFECT: method makes it possible to refuse extra-anatomical shunting, safely form a proximal anastomosis during bifurcation shunting, restore blood flow in the lower extremities, reduce the length of the shunt due to the anatomical location of the prosthesis along the arteries, reduce the risks of infection and thrombosis of the prosthesis.

1 cl, 7 dwg, 2 tbl, 2 ex

Description

The proposed invention relates to medicine, namely to vascular surgery, and can be used to treat patients with arterial insufficiency of the lower extremities with a dissecting aortic aneurysm with lower extremity malperfusion syndrome.

The frequency of dissecting aortic aneurysms is 0.5-10/100 thousand of the population, in the first 2 weeks. 74% of patients die from the debut of the disease. Acute aortic dissection is diagnosed in a timely manner only in 15% of cases, due to the rapid clinical course and inevitable death. Aortic dissection is its most dangerous condition due to the possible development of a fatal outcome and occurs in the United States three times more often than abdominal aortic rupture. Among acute dissecting aortic aneurysms, type B accounts for 37.7-54.5% of cases. [Guidelines for surgery of thoracoabdominal aortic aneurysms, Yu.V. Belov, R.N. Komarov, 2010, p. 46]. Lower limb malperfusion syndrome occurs in approximately 40% of cases of complications of type B aortic dissection. [Gargiulo M, Bianchini Massoni C, Gallitto E, Freyrie A, Trimarchi S, Faggioli G, Stella A. review. Ann Cardiothorac Surg. 2014 Jul;3(4):351-67.]

The operation of extraanatomical “axillary-femoral shunting” was accepted as an analogue.

The thoracic fascia is dissected and the fibers of the clavicular part of the pectoralis major muscle are separated, then the 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 channel 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 channel 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 twisting suture with a 5.0 polypropylene thread using standard techniques [Manual of vascular surgery, Yu.V. Belov, 2011, pp. 117-119].

The closest analogue is the method of "aorto-femoral bifurcation bypass" with the imposition of a proximal clamp on the aorta.

The infrarenal aorta can be isolated through a transperitoneal or retroperitoneal approach. Clamp the aorta above the proposed site of the anastomosis. Produce a longitudinal aortotomy. The aortic bifurcation prosthesis is cut obliquely and aligned according to the size of the aortotomy incision. The prosthesis is anastomosed with the aorta with a continuous suture with monofilament non-absorbable suture material No. 3-0. Strong sutures are applied to the aorta with wide ties. After completion of the anastomosis, the aortic clamps are removed from the aorta and clamped onto the Dacron prosthesis. Produce tunneling to the groin. A tunnel is formed from the aorta to the femoral arteries along the iliac arteries using a digital dissection. Next, anastomoses are formed between the branches of the prosthesis and the femoral arteries according to the “end-to-side” type with a continuous twisting suture with a 5.0 polypropylene thread using standard techniques [Atlas of Vascular Surgery, K.K. Zarinsh, B.L. Geverts, 2009, pp. 204-221]

The disadvantages of these methods are:

1. The subcutaneous location of the vascular prosthesis is non-anatomical and unsafe;

2. High frequency of thrombosis of extraanatomic shunts due to their large length,

3. The imposition of a proximal clamp on the aorta is associated with thrombosis of the true lumen, an increase in the false lumen, progression of malperfusion, and aortic rupture.

4. The absence of a specific method for the formation of a proximal anastomosis in aortofemoral bypass.

The objectives of the invention are:

1. To ensure the safety of the method of forming a proximal anastomosis in aorto-femoral bypass,

2. Restore adequate blood flow and function of the lower extremities,

3. Reduce the risks of infection and thrombosis of the prosthesis during revascularization of the lower extremities,

4. Perform a more anatomical position of the prosthesis.

The essence of the invention is the restoration of blood supply to the lower extremities due to the fact that the proximal anastomosis is applied between the true lumen of the dissecting aortic aneurysm and the main branch of the bifurcation prosthesis, and after applying the clamp to the main branch below the proximal anastomosis, a longitudinal prosthetotomy is performed in the area of the proximal anastomosis, then the area of the prosthesis is applied transverse twisting sutures without tension, after which, in the middle of the tomia, the ties are bred, moved apart with a dissector to preserve the integrity of the ties, an aortotomy is performed between the expanded ties with a scalpel, providing antegrade blood flow to the main branch of the prosthesis, twisting ties are tightened, distal anastomoses are formed, the clamp is removed from the main branch of the prosthesis for ensuring blood flow to the lower extremities.

The technical result during the approbation of the invention is achieved through the use of the proposed method of forming a proximal anastomosis in aorto-femoral bypass grafting, which allows you to provide a safe method for the formation of a proximal anastomosis due to the fact that the anastomosis between the true lumen of the dissecting aortic aneurysm and the main branch of the prosthesis is formed without applying clamps to the aorta and aortotomy, performing a longitudinal prosthesis in the area of the proximal anastomosis and imposing loose twisting sutures in the area of the prosthesis, and then spreading the ties and opening the aortic lumen through the prosthetic opening and tightening the wrapping ties to prevent bleeding, then passing the branches of the prosthesis along the iliac arteries and forming the distal anastomoses, thereby restoring arterial blood flow in malperfusion syndrome of the lower extremities. Due to the more anatomical location of the prosthesis (along the arteries), thereby reducing the length of the shunt, the risks of infection and thrombosis of the prosthesis are minimal.

The method was tested in the 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 on 3 patients.

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

All operated patients using the proposed method in the postoperative period complications in the form of: deaths and prosthesis thrombosis were absent. In all cases, blood supply to the lower extremities was restored.

Data on patients who underwent surgery: "extra-anatomical shunting", traditional "aorto-femoral bifurcation shunting" are shown in Table No. 2.

The patients indicated in Table No. 2, operated on with a synthetic prosthesis, had complications in the postoperative period: 4 patients had thrombosis of the prosthesis, followed by amputation of the n/c, in 3 patients the malperfusion syndrome progressed, complicated by a fatal outcome.

For a better understanding of the method of forming a proximal anastomosis in a dissecting aortic aneurysm with lower extremity malperfusion syndrome, in the appendix of Fig. 1-7. Fig 1 - the formation of the proximal anastomosis between the true lumen of the aorta and the prosthesis. Fig - 2 longitudinal prosthesis in the area of the proximal anastomosis Fig - 3 the position of the transverse twist stitches. Fig - 4 clamping below the proximal anastomosis. Fig - 5 aortotomy through the extended couplers. Fig - 6 tightening of transverse twine sutures in the area of prosthesis. Fig - 7 the final view of the proximal anastomosis, where 1 - the true lumen of the aorta, 2 - the false lumen of the aorta, 3 - proximal anastomosis between the aorta and the prosthesis, 4 - longitudinal prosthetotomy, 5 - transverse twisting sutures of the prosthetotomy area, 6 - position of the clamp below the proximal anastomosis , 7 - aortotomy through extended ties,

The method is carried out as follows.

The patient is under endotracheal anesthesia, the position of the patient on the back with a roller placed under the lumbar region. An incision was made in the projection of the femoral arteries along the Ken line, bypassing the lymphatic package laterally. The common, superficial, deep femoral arteries are identified on both sides. Next, a skin incision is made on the abdomen according to the projection of the lateral edge of the rectus abdominis muscle on the left. Starting from the costal arch down, not reaching 3 cm to the inguinal fold. Having exposed the edge of the fascial sheath of the rectus abdominis muscle, the aponeurosis is cut with an electric knife and reaches the peritoneum. The peritoneum is bluntly removed from the fascia and muscles by a blunt (tupfer and hand) and retracted medially. A diaper is placed in the wound from the side of the peritoneum and the peritoneum is removed medially with two deep and wide hooks. At this point, the anesthesiologist tilts the operating table away from the surgeon. The region of the infrarenal aorta is freed from para-aortic tissue in such a way that it is possible to visualize the dissection of the aorta with the boundaries of the true and false lumen. Next, the bifurcation prosthesis is cut obliquely. They begin to form a proximal anastomosis (3) between the main branch of the Dacron prosthesis and the true lumen of the aorta according to the "end-to-side" type with a continuous twisting suture with a 4.0 Prolene thread, without applying a clamp to the aorta and aortotomy in the area of the true lumen of the aorta (Fig. 1). Having completed the formation of the proximal anastomosis, an aortic clamp (6) is applied to the main branch of the prosthesis below the proximal anastomosis (Fig. 4). Next, perform a longitudinal prosthesis (4) in the area of the proximal anastomosis (Fig. 2). On prosthetotomy hole impose transverse twisted seams (5) (Fig. 3). The suture bands are not tightened, and in the area of the middle of the tomy, the bands are moved apart by a dissector in order to prevent damage to the bands. Further, aortotomy (7) is performed through the expanded ties of the prosthetic opening (Fig. 5). Get a powerful antegrade blood flow. The ties are tightened (Fig. 6). Perform adaptation of the proximal anastomosis. Next, tunneling is performed along the iliac arteries to the femoral arteries by digital dissection. Clamps are applied to the common, superficial, deep femoral arteries on one side. Produce an arteriotomy. Next, I obliquely cut the branch of the prosthesis according to the arteriotomy hole. A distal anastomosis is formed between the branch of the prosthesis and the femoral arteries according to the "end-to-side" type with a continuously twisted thread of Prolene 6.0. Anastamosis adaptation. Starting blood flow in the limb. Clamps are applied to the common, superficial, deep femoral arteries on the other side. Produce an arteriotomy. Next, I obliquely cut the branch of the prosthesis according to the arteriotomy hole. A distal anastomosis is formed between the prosthesis branch and the femoral arteries according to the "end-to-side" type with a continuously twisting suture with a 6.0 prolene thread. Anastamosis adaptation. Starting blood flow to the other limb.

Example 1. Patient SPT, 68 years old, with a diagnosis of Acute dissection of the aorta 3B tin according to DeBakey-Belov; Acute arterial insufficiency of the MB of both lower extremities, an operation was performed: non-occlusive aorto-femoral bifurcation bypass prosthesis, which was carried out as follows: the patient was under endotracheal anesthesia, the position of the patient on his back. Retroperitoneal access was used to access the aorta and iliac arteries. The aortic bifurcation area was freed from para-aortic tissue. Further, in the area of the unaffected area of the aorta (true lumen), an anastomosis was formed between the aorta and the prosthesis according to the "end to side" type. A clamp is placed on the prosthesis below the anastomosis. Longitudinal prosthesis in the area of the proximal anastomosis. Loose ties are applied to the area of the tomia. The ties are moved apart by a dissector. Aortotomy was performed through the prosthetic opening. Received a powerful blood flow. The straps are tight. Hemostasis. Dry. Branches of the prosthesis were carried out along the iliac arteries to the region of the femoral arteries. Further, distal anastomoses were formed between the branches of the prosthesis and the common femoral artery on both sides according to the "end-to-side" type. Hemostasis. Dry. Drainage of wounds on the thighs, behind the hole. Suturing.

The postoperative period proceeded without complications. Lower limbs without ischemia. The patient was in the conditions of the department of anesthesiology and resuscitation. The condition corresponded to the terms and volume of the transferred operation. Consciousness is clear, contact. BP 125/80 mmHg Art., pulse 74 per minute, respiratory rate 18 per minute. Pulsation in the projection of the main arteries of the lower extremities is determined on both sides at all levels. There were no septic complications in the patient. When re-examined a month after the operation, the patient's condition is satisfactory, consciousness is clear. BP 135/80 mmHg Art., pulse 64, respiratory rate 16 per minute. Pulsation in the projection of the main arteries of the lower extremities is determined on both sides at all levels. There are no septic complications, thrombosis of the reconstruction zone in the patient.

Example 2. Patient V.S.D. 63 years old, with a diagnosis of Acute aortic dissection 3B tina according to DeBakey-Belov; Acute arterial insufficiency of the MB of the stage of both lower extremities, an operation was performed: non-occlusive aorto-femoral bifurcation bypass grafting. The operation was carried out according to the above method.

The postoperative period proceeded without complications. Lower limbs without ischemia. The patient was in the conditions of the department of anesthesiology and resuscitation. The condition corresponded to the terms and volume of the transferred operation. Consciousness is clear, contact. BP 115/85 mmHg Art., pulse 62 per minute, respiratory rate 18 per minute. Pulsation in the projection of the main arteries of the lower extremities is determined on both sides at all levels. When re-examined a month after the operation, the patient's condition is satisfactory, consciousness is clear. BP 120/65 mm Hg. Art., pulse 64, respiratory rate 16 per minute. Pulsation in the projection of the main arteries of the lower extremities is determined on both sides at all levels. Septic complications, thrombosis of the reconstruction zone were not detected in the patient.

Patients P.S.A. 59 years old, S.E.G. 74 years old, O.M.T. 71 y., S.E.G. 74 years old, O.M.T. 71 l., the operation was carried out according to the above method.

Claims (1)

A method for forming a proximal anastomosis in a dissecting aortic aneurysm with lower limb malperfusion syndrome, including providing access to the infrarenal aorta, forming a proximal anastomosis between the prosthesis and the aorta, applying a clamp to the prosthesis, digital tunneling from the aorta to the femoral arteries, and also forming distal anastomoses between the branches prosthesis and femoral arteries, characterized in that the proximal anastomosis is applied between the true lumen of the dissecting aortic aneurysm and the main branch of the bifurcation prosthesis, and after clamping the main branch below the proximal anastomosis, a longitudinal prosthetotomy is performed in the area of the proximal anastomosis, then transverse twist sutures are applied to the area of the prosthesis without tension, after which, in the middle of the tomia, the ties are bred, moved apart with a dissector to preserve the integrity of the ties, an aortotomy is performed between the expanded ties with a scalpel, providing antegrade blood flow to the main branch of the prosthesis, tightening the twisting ties, forming distal anastomoses, removing the clamp from the main branch of the prosthesis to ensure blood flow in lower limbs.

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