RU2827320C1 - Ultrasound-guided vacuum-aspiration venous thrombectomy from iliofemoral segment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to vascular surgery, and can be used for treatment of acute, subacute and floating thrombosis in iliofemoral segment. Under ultrasound navigation, a common femoral vein is punctured, an introducer is inserted into it, a Fogarty catheter is inserted above a thrombus head and inflated over the entire lumen of the vein. An introducer is inserted into the involved superficial femoral vein under local anesthesia. It is introduced into common femoral vein under ultrasound guidance. An aspiration tube connected to a high-pressure suction is inserted into the affected segment through an introducer; a vacuum-aspiration thrombectomy is performed from the iliofemoral segment. An ultrasound control is performed; if there are no residual thrombosis phenomena, the balloon catheter is deflated and removed, and both introducer sheaths are removed.

EFFECT: method eliminates the risks of developing and aggravating renal failure in the absence of the need for an angiographic installation, the presence of a specially trained endovascular team of surgeons, eliminates X-ray exposure of medical personnel and patient.

1 cl, 6 dwg, 1 ex

Description

The invention relates to the field of medicine, namely to vascular surgery, and can be used to treat acute, subacute and floating thromboses in the iliofemoral segment.

It is known that acute deep vein thrombosis is a common disease and occurs in 10-20% of the population. An extremely life-threatening situation occurs with a floating thrombus, due to the development of pulmonary embolism (PE). Pulmonary embolism in 6.2% of cases leads to death [1].

Various methods of open and semi-open thrombectomy have been known for a long time, but they all have significant drawbacks and are not able to 100% eliminate the risk of thromboembolism during surgical treatment.

The traditional method of surgical removal of blood clots consists of isolating and exposing the affected vessel and making an incision in its wall. Using a balloon catheter inserted through the incision in the vessel wall, the thrombus is captured and extracted [2]. If the thrombus spreads to large vessels located in the abdominal cavity, anesthesia, laparotomy, and traumatic isolation of the affected vessel are required. The use of this method in elderly and senile patients, as well as in patients with severe concomitant pathology or who have previously undergone interventions on the abdominal organs, is practically impossible, since this operation causes quite a lot of trauma to the abdominal organs and the vessel itself. Another disadvantage is the need for general anesthesia.

A method of inferior vena cava plication is known [2], the advantage of which is the prevention of pulmonary embolism, but this method has many more disadvantages, and they are very significant: general anesthesia, laparotomy (traumatic), trauma to internal organs and the vessel wall. In addition, with this intervention there is a high risk of thrombosis of the inferior vena cava, with the development of inferior vena cava syndrome, severe chronic venous insufficiency of the lower extremities and pelvic organs.

A method of thrombectomy using a Fogarty catheter [2] from the iliac segment is known, with the possibility of restoring the main blood flow in the affected segment. However, this method has a high risk of intraoperative pulmonary embolism due to the lack of control when passing the catheter through the thrombus masses, and the lack of control when removing the thrombus is also a negative factor.

A method of surgical treatment of patients with thrombosis with venous damage in the iliofemoral segment is known, using a device for aspiration of blood clots from arteries and veins - Penumbra [3, 4], which we took as a prototype. In this method, under local anesthesia, through a puncture access in the groin area (or popliteal area), a puncture of the affected vein is performed. An introducer is installed in the lumen of the vein under X-ray control, a catheter is inserted along the diagnostic conductor, through the previously installed introducer, and diagnostic phlebography is performed using a contrast agent in order to determine the upper boundaries of the thrombus and assess the presence of flotation. Then, the diagnostic catheter is replaced with a guiding catheter with a separator, the thrombi are loosened by the latter, the catheter is connected to the penumbra device, and the thrombi are sucked into the flask of the device. Control phlebography is performed and, if there are no residual thrombosis phenomena in the surgical treatment area, the catheter is removed. The introducer is removed. Hemostasis is achieved by digital pressure on the puncture site and applying a pressure bandage. This method has its drawbacks: the technique involves the use of an angiographic unit, which only a few hospitals have, the patient and the surgical team receive X-ray irradiation during this operation, and the use of a contrast agent is necessary here. All this limits the use of this technique in patients with severe forms of chronic renal failure, and also increases the risk of developing acute renal failure, as well as aggravating the existing, chronic one.

The essence of the proposed invention lies in a set of essential features sufficient to achieve the desired technical result, consisting in eliminating the risks of development and worsening of renal failure, the absence of the need for an angiographic installation and the presence of a specially trained surgical (endovascular) team of surgeons, as well as the absence of X-ray irradiation of medical personnel and the patient himself.

The essence of the method of vacuum-aspiration venous thrombectomy from the iliofemoral segment under ultrasound navigation includes puncture of the vein on the side of the lesion under local anesthesia, installation of an introducer into it, insertion of a catheter through it, performance of vacuum-aspiration thrombectomy, achievement of hemostasis by digital pressing of the puncture site, and application of a pressure bandage. Puncture of the common femoral vein, installation of an introducer into it, insertion of a Fogarty catheter above the thrombus head, and its inflation to the entire lumen of the vein are performed under ultrasound navigation. An introducer is installed into the affected superficial femoral vein under local anesthesia, under the control of ultrasound navigation, it is inserted into the common femoral vein. An aspiration tube connected to a high-pressure suction device is inserted into the affected segment through the introducer. Vacuum-aspiration thrombectomy from the iliofemoral segment is performed. Perform ultrasound control. If there are no residual thrombosis effects, the balloon catheter is deflated and removed, both introducers are removed.

The introduction of an introducer into the common femoral artery is performed for the purpose of subsequently introducing a balloon catheter above the head of the thrombus.

In the proposed method, the use of local anesthesia ensures not only the possibility of puncturing and installing introducers, but also the performance of the entire surgical intervention.

Puncture of the superficial femoral vein, followed by installation of a large-diameter introducer, ensures the introduction of an aspiration tube into the affected segment.

Inflation of the balloon catheter in the affected segment, above the thrombus head, provides complete protection against intraoperative pulmonary embolism.

An aspiration tube inserted through an introducer installed in the common femoral vein and connected to a high-pressure suction device ensures complete removal of thrombi from the iliofemoral segment.

All surgical treatment is performed exclusively under ultrasound control, including postoperative control.

The method is illustrated by X-ray images, which use the following symbols: 1 - thrombus; 2 - common femoral vein; 3 - saphenofemoral junction; 4 - Fogarty balloon catheter; 5 - introducer; 6 - large-diameter introducer; 7 - puncture sites of the common femoral and superficial femoral veins.

Fig. 1 shows an intraoperative image of a floating thrombus in the common femoral vein;

Fig. 2 - intraoperative image of the inflated Fogarty balloon catheter above the head of the thrombus;

Fig. 3 - introducers installed in the affected segment;

Fig. 4 - ultrasound control after thrombectomy, the saphenofemoral junction and common femoral vein are completely stained;

Fig. 5 - ultrasound control after thrombectomy, the distal part of the common femoral vein is completely stained;

Fig. 6 - puncture sites of the common femoral and superficial femoral veins.

The method is carried out as follows.

Under local anesthesia, a puncture of the common femoral vein is performed on the affected side, an introducer is installed in the latter under ultrasound navigation, a Fogarty catheter is inserted through it above the thrombus head and inflated to the entire lumen of the vein under ultrasound control. Under local anesthesia, an introducer is installed in the affected superficial femoral vein and, under ultrasound navigation control, it is inserted into the common femoral vein. An aspiration tube connected to a high-pressure suction device is inserted into the affected segment through the introducer. Vacuum aspiration thrombectomy is performed from the iliofemoral segment. Ultrasound control is performed to assess the patency of the iliofemoral segment. If there are no residual effects of thrombosis, the balloon catheter is deflated and removed, both introducers are removed.

Clinical example

Patient D., 53 years old, was admitted to the vascular surgery department of Kazan City Clinical Hospital No. 7 on September 26, 2023, as an emergency, complaining of pain and swelling of the left lower limb. Diagnosis upon admission: Acute deep vein thrombosis of the left lower limb with thrombus head flotation in the deep veins over 7 centimeters. According to vital indications, the following surgery was performed: Vacuum aspiration venous thrombectomy from the iliofemoral segments on the left.

Under local anesthesia, under ultrasound navigation control, a puncture of the proximal iliac vein was performed, into which an introducer was installed. Through the introducer, under ultrasound navigation control, a Fogarty balloon catheter was inserted into the external iliac vein, which was inflated to the entire lumen of the external iliac vein. Under local anesthesia, under ultrasound navigation control, an introducer was installed in the affected superficial femoral vein, through which an aspiration tube connected to a high-pressure suction was inserted into the common femoral vein. Vacuum aspiration thrombectomy was performed from the left common femoral vein. Intraoperative ultrasound control of the iliofemoral segment was performed. The external iliac, common femoral, and deep femoral veins are patent, there is no data on residual thrombosis. Both balloon catheters were deflated and removed, both introducers were removed. Hemostasis of puncture sites was achieved by digital pressure.

In the postoperative period, the patient received the following treatment: Anticoagulant therapy (fraxiparine 0.6 mg × 2 times a day subcutaneously). On September 27, 2023, the patient underwent a control ultrasound Doppler examination of the veins of the lower extremities, according to which there is no evidence of rethrombosis. On September 30, 2023, the patient was discharged in a satisfactory condition under the supervision of a surgeon at the place of residence.

Claims (1)

A method of vacuum-aspiration venous thrombectomy from the iliofemoral segment under ultrasound navigation, including puncture of the vein on the affected side under local anesthesia, installation of an introducer into it, insertion of a catheter through it, performance of vacuum-aspiration thrombectomy, achievement of hemostasis by digital pressure on the puncture site and application of a pressure bandage, characterized in that puncture of the common femoral vein, installation of an introducer into it, insertion of a Fogarty catheter above the head of the thrombus and its inflation to the entire lumen of the vein are performed under ultrasound navigation, an introducer is installed into the affected superficial femoral vein under local anesthesia, it is inserted into the common femoral vein under ultrasound navigation control, an aspiration tube connected to a high-pressure suction device is inserted into the affected segment through the introducer, vacuum-aspiration thrombectomy from the iliofemoral segment is performed, ultrasound is performed control, if there are no residual effects of thrombosis, the balloon catheter is deflated and removed, both introducers are removed.