RU2843479C1 - Method of bifurcation prosthetics of brachiocephalic trunk - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, particularly to cardiovascular surgery. After a proximal anastomosis is formed between the bifurcation prosthesis with the ascending aorta, the subclavian artery is prosthetized with one of the prosthesis branches. That is followed by making the additional incisions in both branches of the bifurcation prosthesis at 2 cm from their mouth, and the temporary shunt is inserted one by one first into the branch of the right subclavian artery. An end-to-end anastomosis is formed between the common carotid artery and a branch of the bifurcation prosthesis into a lumen of the common carotid artery through a second branch of the bifurcation prosthesis.

EFFECT: method allows to ensure the prevention of ischemic damage to the right cerebral hemisphere, especially in cases of an open Willis' circle and/or haemodynamically significant stenosis/occlusion of the contralateral carotid artery, preserving the continuous antegrade cerebral blood flow when forming the anastomosis with the right common carotid artery during the bifurcation prosthetics of the brachiocephalic trunk.

1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, in particular to cardiovascular surgery, and can be used in bifurcation prosthetics of the brachiocephalic trunk for the purpose of intraoperative preservation of antegrade blood flow in the right carotid artery.

According to literature data, the incidence of stenotic-occlusive lesions of one of the main arteries of the aortic arch - the brachiocephalic trunk - is 0.5-6.4% and can lead to significant hemodynamic changes caused by ischemia of the brain and upper limb (visual impairment, transient ischemic attack, ataxia and dizziness) [1].

Endovascular treatment for atherosclerotic lesions of the brachiocephalic trunk, despite a lower level of early postoperative complications and mortality compared to open surgery, can lead to stent fractures and arterial restenosis in the late stages [2, 3]. In addition, performing such endovascular procedures requires significant operator experience [4].

Open surgical treatment is associated with better results in terms of restenosis. Currently, autologous vein and synthetic prosthesis are used as conduits in surgical reconstruction of arteries. In this case, the use of a prosthesis is preferable due to its larger diameter and greater resistance to kinking compared to autologous plastic material [5].

A method of intraoperative perfusion of the common carotid artery during bifurcation prosthetics of the brachiocephalic trunk is known, when one of the branches of the bifurcation prosthesis is used as a “donor” for a temporary shunt [6].

This method is the closest to the declared one in terms of technical essence and the achieved result and was chosen as a prototype.

The disadvantage of this method is the interruption of perfusion upon completion of the formation of the distal anastomosis with the common carotid artery, the probable risk of aero- and material embolism, the relative complexity of installing a temporary shunt and “overloading” of the surgical field.

The aim of the invention is the intraoperative preservation of antegrade blood flow in the right carotid artery by creating continuous perfusion of the brain without reducing the precision of the surgical technique of vascular suturing.

The stated objective is achieved by the fact that after forming the proximal anastomosis between the bifurcation prosthesis with the ascending aorta, the subclavian artery is prosthetized with one of the branches of the prosthesis. Additional incisions are made in both branches of the bifurcation prosthesis at a distance of 2 cm from their mouth and one end of the temporary shunt is inserted into the branch of the bifurcation prosthesis for the subclavian artery, and the other end of the temporary shunt is inserted into the lumen of the common carotid artery through the second branch of the bifurcation prosthesis and an anastomosis is formed between the common carotid artery and the branch of the bifurcation prosthesis according to the "end-to-end" type.

What is new in the proposed method is the introduction of a temporary shunt with one end into the branch of the prosthetic right subclavian artery, and the other end into the lumen of the right common carotid artery through the second branch of the bifurcation prosthesis.

The technical result is the preservation of continuous antegrade cerebral blood flow during the formation of an anastomosis with the right common carotid artery during bifurcation prosthetics of the brachiocephalic trunk.

This method allows for the prevention of ischemic damage to the right hemisphere of the brain, especially in cases of an incomplete circle of Willis and/or hemodynamically significant stenosis/occlusion of the contralateral carotid artery.

The new essential features of the invention have demonstrated in the claimed set new properties that do not clearly follow from the level of technology in this area and are not obvious to a specialist.

An identical set of features was not found in the patent and scientific medical literature.

The proposed method can be used in cardiovascular surgery to improve the quality of treatment.

Based on the above, the proposed invention should be considered as meeting the patentability conditions of “novelty”, “inventive step”, “industrial applicability”.

The invention will be clear from the following description and the accompanying figures.

Fig. 1 shows the brachiocephalic trunk: 1 - ascending aorta, 2 - main branch of the bifurcation prosthesis, 3 - branch of the bifurcation prosthesis for the subclavian artery, 4 - subclavian artery, 5 - branch of the bifurcation prosthesis for the carotid artery, 6 - common carotid artery, 7 - temporary bypass.

The method is carried out as follows. After lateral pressing of the ascending aorta 1, its lumen is opened longitudinally along the anterior wall for 3 cm. The main branch of the bifurcation prosthesis 2 is prepared to form a proximal anastomosis. Then, an anastomosis is performed using an end-to-side wrap suture with 4/0 polypropylene thread between the main branch of the bifurcation prosthesis 2 and the ascending aorta 1. Upon its completion, one of the branches of the bifurcation prosthesis 3 is advanced to the area of the right subclavian artery 4. After it is clamped, the lumen of the subclavian artery is opened longitudinally in the 2nd segment 4 and a distal anastomosis is formed between the subclavian artery 4 and the branch of the bifurcation prosthesis 3 using an end-to-side wrap suture with 5/0 or 6/0 polypropylene thread, then the blood flow is allowed through the subclavian artery 4. After which the right subclavian artery 4 is ligated at the orifice. Then the second branch of the bifurcation prosthesis 5 is advanced to the area of the right carotid triangle. Through punctures in both branches of the bifurcation prosthesis, a temporary shunt 7 is alternately inserted first into the branch of the right subclavian artery 3, then into the lumen of the common carotid artery 6 through the second branch of the bifurcation prosthesis 5. Against this background, a distal anastomosis is applied between the second branch of the bifurcation prosthesis 5 and the common carotid artery 6 according to the "end-to-end" type. The common carotid artery 6 is ligated at the mouth. Upon completion of the anastomosis, the temporary shunt 7 is removed and the operation is completed by draining the wounds and suturing the tissues in layers.

Clinical example.

Patient K., 72 years old, was admitted to hospital with a diagnosis of subocclusion of the brachiocephalic trunk, which was confirmed by the results of echocardiography and spiral computed tomography of the aortic arch vessels.

The main stage of the operation was performed in the following sequence. After performing mini-J sternotomy in the 4th intercostal space, the ascending aorta, the brachiocephalic trunk along its length, and also the right subclavian artery and the right common carotid artery from separate incisions were isolated. Given the anatomical feature of the patient (short brachiocephalic trunk), linear prosthetics of the vessel was associated with a high risk of neurological complications and bleeding. Given this fact, the appropriate option for surgical treatment of the patient was to perform bifurcation prosthetics of the brachiocephalic trunk.

After administration of the calculated dose of heparin, the ascending aorta was pressed laterally, the lumen of the ascending aorta was opened longitudinally along the anterior wall. A proximal anastomosis was created between the ascending aorta and the main branch of the Polymaille 16*8*8 mm bifurcation prosthesis. One of the branches was advanced into the area of the right subclavian artery. The right subclavian artery was clamped with vascular clamps, its lumen was longitudinally opened in the 2nd segment, and a distal anastomosis was formed between the branch of the bifurcation prosthesis and the subclavian artery "end-to-side". After starting the blood flow, the artery was ligated at the orifice. The second branch of the bifurcation prosthesis was advanced into the area of the carotid triangle to form an anastomosis with the common carotid artery. During a test clamping of the common carotid artery, retrograde pressure was measured, which was 22 mm Hg. with systemic systolic blood pressure of 130 mmHg. In addition, infrared spectroscopy data showed a decrease in cerebral oxygenation by more than 20% compared to baseline. The measurements obtained indicate a high risk of developing neurological complications during the planned surgical intervention. Taking this fact into account, carotid artery replacement was performed using the claimed method: for temporary bypass, a Pruitt-Inahara shunt was installed with one end in the branch of the bifurcation prosthesis of the subclavian artery, and the other end in the lumen of the common carotid artery through a puncture in the second branch of the bifurcation prosthesis. After that, cerebral oxygenation indices returned to baseline values. A distal anastomosis was imposed between the second branch of the bifurcation prosthesis and the common carotid artery according to the end-to-end type. The common carotid artery was ligated at the mouth. The temporary bypass was removed without complications. The holes in the branches of the bifurcation prosthesis were sutured with U-shaped sutures. The operation was completed with wound drainage, metal osteosynthesis of the sternum and layer-by-layer wound suturing. The patient was transferred to the intensive care unit.

The patient regained consciousness 4 hours after the end of the operation. With adequate spontaneous breathing, the patient was extubated. Assessment of the neurological status did not reveal focal symptoms from the brain. The next day, the patient was transferred to the general ward. According to the postoperative spiral computed tomography of the aorta and brachiocephalic vessels, no contrast defects, kinks or compression of the prosthesis, including in the anastomosis zone, were noted. The patient was discharged from the hospital in a satisfactory condition on the 10th day after the operation.

The method proposed as an invention was tested on 4 adult patients. Preparation for surgery and anesthetic care were the same for all patients.

The use of the proposed method allows for adequate intraoperative protection of the brain and prevention of the development of transient and irreversible ischemic damage without complicating the technique and technology of surgical intervention.

Literature

1. Nashnoush M, Sahak H, Shin Y, Ahimsadasan R, Raveendran Y, Hanna J et al. Innominate artery occlusion: a case study. J Ultrason 2024; 24: 8. doi: 10.15557/JoU.2024.0008.

2. Usman AA, Resnick SA, Benzuly KH, Beohar N, Eskandari MK. Late stent fractures after endoluminal treatment of ostial supraaortic trunk arterial occlusive lesions. J Vasc Interv Radiol 2010;21:1364-1369.

3. Peterson BG, Resnick SA, Morasch MD, Hassoun HT, Eskandari MK. Aortic arch vessel stenting: a single-center experience using cerebral protection. Arch Surg 2006;141:560-563; discussion: 563-564.

4. Albuquerque FC, Ahmed A, Mitha A, Stiefel M, McDougall CG. Endovascular recanalization of the chronically occluded brachiocephalic and subclavian arteries: technical considerations and an argument for embolic protection. World Neurosurg 2013;80:e327-336.

5. Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A et al. European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease Eur J Vasc Endovasc Surg. 2023;65(1):7-111. doi: 10.1016/j.ejvs.2022.04.011.

6. Matsuzaki K, Mitomi K, Imai A, Sato M. Y-shaped graft replacement of an isolated innominate artery aneurysm via the transmanubrial approach. Interdiscip CardioVasc Thorac Surg 2024; doi:10.1093/icvts/ivae127.

Claims (1)

A method of bifurcation prosthetics of the brachiocephalic trunk, including the use of a temporary shunt, characterized in that after forming a proximal anastomosis between the bifurcation prosthesis with the ascending aorta, the subclavian artery is prosthetized with one of the branches of the prosthesis, then additional incisions are created in both branches of the bifurcation prosthesis at a distance of 2 cm from their mouth and a temporary shunt is alternately inserted first into the branch of the right subclavian artery, then into the lumen of the common carotid artery through the second branch of the bifurcation prosthesis and an anastomosis is formed between the common carotid artery and the branch of the bifurcation prosthesis according to the "end-to-end" type.