RU2239365C2 - Method for surgical treatment of failed valvular venous apparatus - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should longitudinally lance the vein in area of commissures location, proximally and distally, by not achieving the valvular bottom. Reconstruction of failed tricuspid valve with one rudimentary fold the size of which is less against two other ones by more than one third of free edge length should be carried out due to neutralization of rudimentary fold by connecting its commissure points and suturing up free tissue, that is obtaining a bicusoid valve. After that, one should correct the length of free edges of valvular folds due to their tightening up to make the length of free edges of valvular folds to correspond to the length of venous semicircumference at the level of commissures. The method enables to restore normal valvular function.

EFFECT: higher efficiency of surgical therapy.

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Description

The present invention relates to medicine, in particular to vascular surgery, and can be used for the surgical treatment of failed valve apparatus of the veins.

A known method of surgical treatment of failed valves [see Kistner R. Surgical repair of an incompetent femoral vein valve. The surgical archive T.110, 1975, S. 1336-1342]. This known method includes longitudinal section of a vein through the points of commissures and reduction of the cusps by suturing them with a surgical suture.

The method has the following disadvantages: the need for a large section of the vein with the intersection of the lower fibrous ring, which is passed through the point of the upper commissure, which reduces its strength, as well as the strength of the fibrous ring, the application of 2-3 sutures to reduce the area of the cusps and reduces their area contact, and therefore, reduces the closure function of the valve, leads to a large percentage of failures.

There is also known a method for the surgical treatment of insolvent vein valves [see A.S. USSR No. 1674813, 05/06/1991], in accordance with which they tighten the free edges of the valve cusps, bringing its length to the length of the semicircle of the vein at the level of commissures.

The specified method, adopted as a prototype, largely eliminates the disadvantages of the above known method, and is effective in the treatment of stretched flaccid flaps that do not provide a tight closure in the closed state.

However, it is unacceptable for abnormal variants of valve leaflet development, such as, for example, a tricuspid valve, one of whose valves is rudimentary.

The objective of the present invention is to remedy this drawback.

The problem is solved in the present method of surgical treatment of a failed valve apparatus of the veins by means of its reconstruction, including access and opening the veins, for which a vein is cut longitudinally in the region of the upper hemisphere of the valve, the status of the valve apparatus is determined, including the number of valves and their anatomical state. When revealing a tricuspid valve, one of the valves of which is rudimentary (the length of the free edge of this valve is more than 1/3 less than the other two valves), its disharmony (dysplasia, atypicality) is judged and in this case the vestigial valve is neutralized, for which its points are connected the commissure and suture the free tissue of the sash, leading this case to the bicuspid valve, and then adjust the length of the free edges of the valve, pulling their edges in a manner known per se, bringing its length to the length of the semicircle of the vein at the level of SSDS.

The proposed method is further described based on the drawings, where

figure 1 shows a sectional view of an insolvent valve of normal structure with weakened sashes;

figure 2 shows in section a failed valve of atypical structure with three wings, one of which is rudimentary.

figure 3, 4 shows the reconstruction of the insolvent tricuspid valve, one of the valves of which is rudimentary.

The figures depicted in the drawings have the following position names:

1 - a trunk of a vein;

2 - vein wall;

3 - upper fibrous ring;

4 - lower fibrous ring;

5 - valve area;

6 - valve sinus;

7 - line of fastening of the valve leaf;

8 - consolidated edge of the valve leaf;

8 '- rudimentary sash;

9 - cut line of a vein;

10 - bottom of the valve;

11 - left commissure;

12 - the right commissar;

12 '- intermediate commission,

12 '' - neocommission.

The method is carried out in the following way (see figure 1).

After processing the surgical field along the anterior surface of the thigh under the pupartial ligament, a longitudinal incision of the femoral tissues is performed, 12-15 cm long, in the projection of the vascular bundle. In the usual way, a segment of the femoral vein 1 is isolated at the location of the valve 5, which manifests itself as a spheroid extension of this segment of vein 1, as well as a vein above and below this segment. A milking test is carried out to determine the closure function of valve 5: distal to the location of valve 5 on the femoral vein 1, a vascular clamp is applied and the blood is displaced with the finger proximally, after the finger pressure ceases, the blood rushes retrograde and, with good closure function of valve 5, the shutters 8 are closed without passing blood into the subvalvular space, below the bottom of the valve 10, the vein 1 remains desolate, and when the valve 5 is inactive, it is filled with blood.

After verifying the incompetence of valve 5 of the femoral vein 1, after applying the vascular clamp proximally, under an operating microscope (ORTOM), vein 1 is cut longitudinally with a section 9 between commissures 11, 12 above and below their level for 10-15 mm, and the valve is inspected, for which determines the number of valves and their anatomical state, revealing a tricuspid valve, one of whose valves is rudimentary, they are judged atypical and produce valvulopexy with the creation of neocomissure 12 '', suturing the rudimentary valve with a suture and yielding commissures 12 and 12 'into one neocomissure - 12' ', for which an atraumatic thread with a needle 8.0 is inserted through a puncture of the wall of vein 1 at a point of the future commissure 12 and the thread is brought out to the outside of the commissure 12', a knot is knotted outside, forming a new neocomissure 12 ' 'and excluding the negative effect of the rudimentary valve on the valve closure function, then using the excess length of the free edge of the remaining two valves, create their length equal to the length of the semicircle of the vein in the commissure region, both valves 8 are captured with a needle at a distance necessary for To bring their free edge to the length of the semicircle of the vein, retreating 1 mm from the outer edge. An atraumatic thread is passed through the flaps 8, and a needle with a thread is dug out of the vein wall, near the injection site. Outside veins 1 tie 4-5 knots. To the site of nodes inside the vein 1 pull the free edges of both valves 8, the venotomy opening is sutured with a continuous-nodal suture. After that, the proximal vascular clamp is removed, the blood rushes in the retrograde direction, but, reaching the bottom of the valve 10 with closed valves 8 does not penetrate into the subvalvular space, the valve 5 becomes consistent. Layer closure of the surgical wound.

If it is revealed that valve 5 (see Fig. 1) has the same level of commissures 11, 12 and two wings, and its failure is caused by the sagging of the changed free edges of the valves, then the reconstruction is performed in accordance with the known in A. USSR No. 1674813 of May 8, 1991 by way. This method does not provide guidance in cases where the failure of the valve 5 is due to other reasons, the elimination of which is not considered in the present invention. The described method was tested on 9 patients during 1994-1999.

Example 1

Patient K., 36 years old, medical history No. 1457, was admitted to the clinic for varicose veins of the left lower limb 111A. With complaints of dilated saphenous veins on the left lower limb, swelling of the limb after 2 hours of standing, fatigue and bursting pain in the calf muscles with prolonged stay on the legs. Ultrasound dopplerography of the veins of the lower extremities and retrograde femoral phlebography, which revealed the failure of the proximal valve of the femoral vein, were performed in the patient’s department.

Operation: microsurgical reconstruction of an unstable atypical valve of the femoral vein. After epidural anesthesia after processing the surgical field, an incision was made in the upper third of the left thigh 12 cm long. The skin was cut subcutaneous tissue, fascia of the thigh. A vascular bundle and a femoral vein have been isolated. In the femoral vein, a valve is determined in the form of a spheroidal expansion of the vein, through the wall of which commissures are visible. Distal to the valve, a vascular clamp is applied to the vein and the blood is displaced in the proximal direction, when pressure ceases with a finger, the blood rushes retrograde and freely penetrates the subvalvular space (finger test), which confirms the absence of the valve closure function. Superimposed vascular clamps on the femoral vein, proximal to the valve and on the deep femoral vein. Under an operating microscope, with a 5-fold increase, the vein is dissected from the level above the visible commissure by 2 mm downwards for 15 mm. The lumen of the vein was washed with saline NaCl with heparin. An intravenous valve audit was performed. It was revealed that there is a tricuspid valve, one of the valves of which is rudimentary - the length of the free edges of the two valves is 18 mm, the vestigial is 5 mm, the valves are normoplastic.

To eliminate the valve defect, an atraumatic suture 8.0 is inserted through a puncture of the vein wall from the outside to the inside, at the point of an intermediate commissure into the lumen of the vein, the free edges of both cusps of normal cusps are captured with an atramatic suture needle, 1 mm from the free edge, and punctured at the point of commissure 13 with the reduction of the length of the free edge of the valves to the length of the semicircle of the vein. Then the atraumatic thread with the needle was brought out of the vein wall through a puncture near the injection point. By applying 5 knots outside the wall of the vein, the flaps are pulled up to the neocomissure level of 12 '' with the length of their free edge being reduced to the length of the semicircle of the vein. The venotomy opening was sutured with a continuous-nodal suture. After removing the proximal clamp, the blood did not penetrate into the subvalvular space, below the closed valve flaps, i.e. valve viability restored. Layer wound closure. A superficial venectomy was performed according to Beccoccus, Coquette, sutures were applied to wounds, an aseptic dressing, elastic bandaging of the limb.

In the postoperative period, the patient was prescribed heparin subcutaneously, antibacterial therapy. Sutures were removed on day 10, healing by first intention. There are no complaints of the patient about dilated veins, swelling of the limbs and pain in the calf muscles. Control ultrasound dopplerography showed the viability of the valve.

Examination of the patient (after a year, 3 years, 5 years) established a persistent clinical effect. During this time, the disappeared manifestations of the disease did not resume. Control ultrasound dopplerography showed that the reconstructed venous valve is consistent.

Example 2

Patient V., 28 years old, medical history No. 3182, was admitted to the hospital for varicose veins of the right lower limb 111A. With complaints of dilated saphenous veins on the right lower limb, its edema, fatigue and bursting pain in the calf muscles with prolonged stay on the legs. After ultrasound dopplerography of the veins of the lower extremities and retrograde femoral phlebography revealed the failure of the proximal valve of the femoral vein.

Operation: microsurgical reconstruction of an unstable atypical valve of the femoral vein. After epidural anesthesia, after processing the surgical field, an incision was made in the upper third of the left thigh 12 cm long. The skin, subcutaneous tissue, and fascia of the thigh were dissected. A vascular bundle is isolated, and a femoral vein is formed from it. In the femoral vein, a valve is determined in the form of a spheroidal expansion of the vein, through the wall of which commissures are visible. Distal to the valve, a vascular clamp is applied to the vein and the blood is displaced in the proximal direction, when pressure ceases with a finger, the blood rushes retrograde and freely penetrates the subvalvular space (finger test), confirming the absence of the valve closure function. Superimposed vascular clamps on the femoral vein proximal to the valve and on the deep femoral vein. Under an operating microscope, with a 5-fold increase, the vein is dissected from the level above the visible commissure by 2 mm downwards for 15 mm. The lumen of the vein is washed with saline with heparin. An intravenous audit of the valve was performed, it was revealed that there is a tricuspid valve, one of the valves of which is rudimentary with the length of the free edges of the two valves 18 mm, vestigial 4 mm, the valves are normoplastic. An atraumatic thread 8.0 was drawn through a puncture of the vein wall from the outside to the inside, at the point of commissure 12, the thread was inserted into the lumen of the vein, the free edges of both normal cusps were caught with an atramatic thread, 1 mm from the free edge, and punctured at the commissure point 12 'with the reduction the length of the free edge of the vein folds to the length of the semicircle of the vein. Atraumatic thread with a needle brought out of the vein wall through a puncture near the injection point. By applying 5 knots outside the vein wall, the flaps are pulled up to the neocomissure level of 12 '' with the reduction of the length of their free edge to the length of the semicircle of the vein. The venotomy opening is sutured with a continuous-nodal suture. When removing the proximal clamp, the blood rushes retrograde, but does not penetrate into the subvalvular space below the closed valve flaps, the valve is consistent. A superficial venectomy was performed according to Beccoccus, Coquette.

Sutures were applied to the wounds, an aseptic dressing, elastic bandaging of the limb was performed.

In the postoperative period, the patient was prescribed heparin subcutaneously, antibacterial therapy. Sutures were removed on day 10, healing by first intention. The patient has no complaints about dilated veins, swelling of the limbs and pain in the calf muscles. With control ultrasound dopplerography, the valve is consistent.

Also shown in the drawings:

- figure 5 - volumetric diagram of a tricuspid valve with one rudimentary sash;

- 6 is a three-dimensional diagram of the final stage of the operation of suturing the rudimentary sash with a suture with the creation of neocomissure 12 ''.

Claims (1)

A method for the surgical treatment of a failed valve apparatus of the veins by reconstruction, comprising opening a vein in the area of the commissures proximal and distal without cutting the incision to the valve bottom, characterized in that the reconstruction of a failed tricuspid valve with one rudimentary valve, the size of which is smaller than the other two more than 1/3 of the length of the free edge, is produced by neutralizing the rudimentary sash by connecting its commissure points and suturing free tissue, i.e. by bringing this case to a bicuspid valve, then the length of the free edges of the valve cusps is adjusted by pulling them, bringing the length of the free edges of the valve cusps to the length of the semicircle of the vein at the level of commissures.

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