RU2556607C1 - Method for double fastening of neck of aortic aneurismal pouch - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: aorta is completely transected to the level of an expected anastomosis. The aorta is mobilised from the surrounding tissues throughout the anastomosis formation. A portion of a corrugated bifurcated prosthesis is cut away up to 1.5-2 cm long. That is followed by placing its half into an aortic lumen as a pad. Further, the prosthetic anastomosis is formed with a fastened prosthetic pad and a neck of an aneurismal pouch with a locking vessel suture. The same prosthesis segment 3 cm long is put on the prosthesis as a cuff, and an anastomosis line is covered.

EFFECT: method enables fastening the neck of the aneurismal pouch reliably, providing the anastomosis tightness and reducing the intraoperative blood loss by using the prosthetic portions for fastening.

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Description

The invention relates to medicine, namely to cardiovascular surgery.

Known methods for applying a proximal anastomosis for aortic prosthetics after resection of the aneurysm are Clinical Angiology. A manual for doctors edited by Acad. RAMS A.V. Pokrovsky. Moscow, “Medicine”, 2004, volume II, p.194. The operation involves resection of the aortic aneurysm, the imposition of a proximal prosthesis anastomosis with the neck of the aneurysmal sac, end-to-end type with an upholstered vascular suture. Disadvantages:

- eruption of the neck of the aneurysmal sac and, accordingly, insufficient tightness of the anastomosis;

- technical difficulties of visual inspection when suturing the posterior semicircle;

- the ability to use only with the consistency, strength of the aortic wall in the neck of the aneurysmal sac.

Closest to the claimed is a method of strengthening and sealing aortic anastomoses in surgery of the thoracic aorta. Alekseev I.A. Abstract of dissertation for the degree of candidate of medical sciences. - M., 2009, 003489107.

It is most optimal to form an anastomosis, strengthening it with a teflon strip around the entire circumference of the anastomosis. To do this, completely cross the aorta at the level of the proposed anastomosis and mobilize it from surrounding tissues for at least 1.5-2 cm. A strip 5 mm wide and a length corresponding to or greater than the length of the circumference of the anastomosis is cut out of Teflon felt 1 or 1.5 mm thick. .

Anastomosis of a vascular prosthesis with an aorta is formed according to the end-to-end type by a continuous twisted seam with a thread of 2/0, 3/0 or 4/0 and needles of 26 or 30 mm. When laying the sutures, special attention is paid to ensure that the aortic wall is located between the prosthesis and the Teflon strip, which helps to relieve sutures and ensures minimal impact of threads on the aortic tissue. This is precisely the main component of "strengthening the anastomosis." Additional tightness is created due to the fact that the injections were covered with Teflon. In addition to reinforcing strips, gaskets use biological adhesive, which further strengthens and seals the anastomosis and leads to hemostasis even against the background of coagulopathy.

A single 5 ml cartridge is enough to handle two to three aortic anastomoses. Glue is applied to the finished anastomosis of the vascular prosthesis with the aorta with a thin layer 10-15 mm wide, completely covering the suture. Particular attention is paid to the surface of the anastomoses:

the anastomoses are preliminarily carefully dried with napkins and protected from getting wet for 1.5-2 minutes, which allows the adhesive to polymerize. It should also be noted that even a slight leakage or leakage of blood along the suture line leads to impaired adhesion of the adhesive to the surface of the anastomosis, therefore, before applying the adhesive, blood is evacuated from the inside of the aorta by coronary suction or drainage of the left ventricle, depending on the situation.

After complete polymerization of the glue, the clamp is removed from the aorta in 1.5-2 minutes. In the event of the appearance of a jet source of bleeding from the anastomosis, additional sutures are put to stop it, since the adhesive hardens and forms rubber-like masses on the surface of the anastomosis that are easily pierced. Upon completion, all anastomoses are evaluated in terms of tightness. Bleeding areas are usually sutured with separate sutures on Teflon pads.

The disadvantages of the method:

- the use of Teflon pads with a width of 5 mm technically complicates the stitching of the latter with the aortic wall from the inside;

- economic costs of biological glue;

- the need for absolute dryness of the anastomosis before applying glue, which is difficult when performing reconstruction on the aorta.

The objective of the invention is to develop an effective method for the formation and strengthening of the proximal anastomosis during prosthetics of the aorta after resection of the aneurysm of the abdominal region. Increasing the tightness of the anastomosis of the aortic prosthesis and reducing intraoperative blood loss.

SUMMARY OF THE INVENTION With aortic aneurysms, despite the thrombotic and atherosclerotic overlays on the intima, the vascular wall itself becomes thinner, including in the neck of the aneurysmal sac. In this regard, in the formation of the proximal anastomosis of the prosthesis and the thinned aortic wall, technical difficulties arise in terms of the formation of a durable hermetic anastomosis, which is the aim of the claimed method.

After mobilization of the aneurysmal sac and neck, an aortic clamp is applied above the aneurysmal sac, vascular clamps on the iliac arteries, aortotomy, removal of thrombotic and atherosclerotic masses, thorough hemostasis. Next, the aneurysm neck is prepared to form a reinforcing pad from an alloprosthesis. For this, thrombintimectomy is performed from the proximal end of the aorta. Part of the prosthesis with a length of up to 1.5-2 cm is excised from the corrugated bifurcation vascular prosthesis. The diameter of the prosthesis should correspond to or slightly less than the diameter of the aorta. A ½ part of the prosthesis is placed into the aortic lumen according to the type of laying and fixed with a twisted vascular suture, while layers lying on top of each other are sutured, teething of the aortic wall is excluded, and the small insert size makes it easy to manipulate the instruments when suturing. At the same time, the neck of the aneurysmal sac is thickened and strengthened for 2-3 cm, which is sufficient to apply a reliable proximal anastomosis. Next, an anastomosis of the prosthesis is formed with a reinforced gasket from the prosthesis, the neck of the aneurysmal sac with an upholstered vascular suture. Next, the same section of the prosthesis 3 cm long is put on the prosthesis in the form of a sleeve, cover the anastomosis line, thereby forming a durable hermetic anastomosis with double reinforcement. The distal anastomosis is formed classically, as it usually overlaps the intact vascular wall and does not need to be strengthened.

Clinical example 1:

Patient B., 74 years old, was hospitalized in the Department of Vascular Surgery of the Republican Clinical Hospital in Nalchik with a diagnosis of giant subrenal aneurysm of the abdominal aorta.

In the department, the patient was examined clinically and laboratory:

- ECG - closed: sinus rhythm, heart rate 78 beats. in min, diffuse changes in the myocardium. Hypertrophy of the right atrium and left ventricle.

- commonly. an. blood er-you 3.6 × 10 ¹² .gb. 121 g / l, cp 0.9 formulations 7.1 × 10 ⁹ , e-1; p-0, s-60, l-19, m-2, ESR 30 mm / h.

- Blood sugar 5.3 mmol / L.

- Ca 2.78 mmol / L.

- Bilirubin 12.0 mmol / l, the reaction is indirect.

- Total protein 63.5 g / l

- Urea 8.4 mmol / L.

- Coagulogram: fibrinogen 2.75 g / l; IPI 96% Nt 41%

- commonly. an. urine col. s / f, acidic reaction, beats. weight 1020, protein neg., sugar neg., flat units in p.z., lake units in p.z.

- Computer angiography of vessels of the lower extremities: zakl. - Aneurysm of the abdominal aorta, starting 3-5 mm below the renal arteries and extending to aortic bifurcation. In the lumen, parietal thrombotic masses.

The patient was operated on: aortic aneurysm was resected, aortic-aortic prosthetics with implantation of the inferior mesenteric artery into a prosthesis with double strengthening of the proximal anastomosis. The duration of the operation is 4 hours. Intraoperative blood loss 350 ml.

The postoperative period was uneventful, the patient was discharged from the hospital on the 11th day after the operation with recommendations.

Clinical example 2:

Patient Sh., 63 years old, was hospitalized in the Department of Vascular Surgery of the Republican Clinical Hospital of Nalchik with a diagnosis of infrarenal aneurysm of the abdominal aorta with stratification.

In the department, the patient was examined clinically and laboratory:

- ECG - closed: sinus rhythm, heart rate 87 beats. in minutes Hypertrophy of the right atrium and left ventricle, incomplete blockade of the right leg of the bundle of His.

- commonly. an. blood er-you 3.2 × 10 ¹² .gb. 101 g / l, cp 0.9 lakes 8.9 × 10 ⁹ , e-1; p-0, s-75, l-21, m-2, ESR 30 mm / h.

- Blood sugar 4.8 mmol / L.

- Ca 2.78 mmol / L.

- Bilirubin 14.8 mmol / l., The reaction is indirect.

- Total protein 70.5 g / l.

- Urea 8.4 mmol / L.

- Coagulogram: fibrinogen 5.75 g / l; IPT 103% NT 41%.

- commonly. en urine col. s / f, acidic reaction, beats. weight 1020, protein neg., sugar neg., flat units in p.z., lake units in p.z.

The patient was operated on an emergency basis: a resection of the aortic aneurysm, aorto-biliac prosthesis with double reinforcement of the proximal anastomosis were performed.

The duration of the operation is 5 hours 30 minutes. Intraoperative blood loss 500 ml.

The postoperative period was uneventful, the patient was discharged from the hospital on the 14th day after the operation with recommendations.

Clinical example 3:

Patient X., 67 years old, was hospitalized in the Department of Vascular Surgery of the Republican Clinical Hospital of Nalchik with a diagnosis of subrenal aneurysm of the abdominal aorta. Tear. Retroperitoneal hematoma.

In the department, the patient was examined clinically and laboratory:

- ECG - closed: sinus rhythm, heart rate 103 beats. in minutes sinus tachycardia.

Hypertrophy of the right atrium and left ventricle.

- commonly. an. blood er-you 3.5 × 10 ¹² .gb. 116 g / l, cp 0.9 lakes 9.1 × 10 ⁹ , e-1; p-0, s-74, l-18, m-2, ESR 26 mm / h.

- Blood sugar 3.7 mmol / L.

- Ca 2.78 mmol / L.

- Bilirubin 18.0 mmol / l., The reaction is indirect.

- Total protein 60.0 g / l, S Urea 10.4 mmol / L.

- Coagulogram: fibrinogen 5.25 g / l; IPT 98% NT 41%.

- commonly. en urine col. s / f, acidic reaction, beats. weight 1025, protein neg., sugar neg., flat units in p.z., lake units in p.z.

The patient was operated on an emergency basis: retroperitoneal hematoma was removed, aortic aneurysm was resected, aorto-biliac prosthetics with double strengthening of the proximal anastomosis were performed.

The duration of the operation is 6 hours 20 minutes. Intraoperative blood loss 750 ml.

The postoperative period was uneventful, the patient was discharged from the hospital on the 17th day after the operation with recommendations.

Technical result:

- technical ease of implementation;

- double strengthening, tightness of the anastomosis and, accordingly, a decrease in intraoperative blood loss;

- the ability to perform aortic prosthetics for subrenal and renal aneurysms and wall weakness in the neck in the absence of AIC;

- reduction of costs, as for strengthening, sections of the same prosthesis from which aortic prosthetics are performed are used.

Claims (1)

A method of double reinforcing the neck of the aneurysmal sac of the aorta, which consists in the complete intersection of the aorta at the level of the putative anastomosis and its mobilization from surrounding tissues during the formation of the anastomosis of the vascular prosthesis with the aorta of the end-to-end type with a continuous twisting vascular suture using a pad for strengthening the anastomosis, characterized the fact that a part of the prosthesis with a length of up to 1.5-2 cm is cut from a corrugated bifurcation vascular prosthesis and placed into the aortic lumen by ½, formation anastomosis of the prosthesis with a reinforced gasket from the prosthesis and the neck of the aneurysmal sac with a twisted vascular suture, the same section of the prosthesis 3 cm long is put on the prosthesis in the form of a sleeve, cover the anastomosis line.