RU2836290C1 - Method for forming a prosthetic "skirt" of a multi-branch aortic prosthesis when performing a distal aortic anastomosis during "elephants trunk" procedure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to cardiovascular surgery. Multi-branch aortic prosthesis is corrugated in the transverse direction to form a duplex along the entire circumference of the multi-branch aortic prosthesis. Then vascular clips are alternately applied on the formed duplex and a prosthetic "skirt" is created. Thereafter, a multi-branch aortic prosthesis is placed in the descending aorta, positioned at the required depth, and a distal aortic anastomosis is formed with the created prosthetic "skirt" with successive removal of the clips from the multi-branch aortic prosthesis.

EFFECT: method enables reducing the length of the surgical intervention, providing the formation of a reliable distal aortic anastomosis with the descending aorta, and improving its sealing.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, in particular to cardiovascular surgery, and can be used in aortic arch prosthetics using the "elephant trunk" technique to form a distal anastomosis of a multi-branch aortic prosthesis with the descending aorta in order to reduce the time required to perform the anastomosis by simplifying the technique for its formation and performing adequate sealing of the anastomosis.

Today, surgical treatment of aneurysms and dissection of the thoracic aorta is a generally accepted standard. One of the main methods is aortic arch replacement using the "elephant trunk" technique (Borst procedure) [1], which is characterized by lowering a part of the prosthesis into the descending aorta below the distal aortic anastomosis. This allows for a significant reduction in surgical trauma during the second stage of reconstructive surgery of the thoracoabdominal aorta.

A particularly important area of surgical intervention is the area of the distal aortic anastomosis with the descending aorta, since this area is difficult to access for manipulations with already reconstructed aortic arch vessels. A significant aspect of the operation is reliable fixation and sealing of the distal aortic anastomosis.

A method is known for forming a distal aortic anastomosis with a hybrid prosthesis for performing the “frozen elephant trunk” procedure using a prosthetic “skirt” embedded in the design at the border with the stent graft, which facilitates and accelerates the process of forming a distal aortic anastomosis and ensures its adequate sealing.

The disadvantage of this method is the fixed length of the prosthesis placed in the descending aorta, which in some cases is insufficient to adequately cover the distal fenestration of the aortic intima.

Performing a distal aortic anastomosis with a multi-branch prosthesis brought down into the descending aorta is technically difficult, as it requires greater control over the passage and tension of the thread, requires the use of spacers when forming the suture, and slows down the performance of this stage of the operation.

No adequate prototype was found in the analyzed patent and scientific-medical literature.

The objective of the invention is to create a method for performing a distal aortic anastomosis with the descending aorta during the “elephant trunk” procedure, ensuring reliable fixation of the aortic prosthesis with the descending aorta, high speed of performing the anastomosis, and improving its sealing.

The task at hand is solved by preliminary corrugation of the aortic prosthesis and application of vascular clips to the formed duplication with the formation of a “skirt” of the aortic prosthesis.

What is new in the proposed method is the option of performing a distal aortic anastomosis of a multi-branch aortic prosthesis with the descending aorta using a formed prosthetic "skirt". This prosthetic "skirt" allows not only to securely fix the prosthesis with the descending aorta, but also to adequately seal the distal aortic anastomosis.

The technical result is a fast and reliable formation of the distal aortic anastomosis with the descending aorta and its adequate sealing.

The new features have demonstrated new properties in the claimed set 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, namely in operations on the aortic arch.

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 formation of a prosthetic "skirt" for performing a distal aortic anastomosis with the descending aorta during the "elephant trunk" procedure, where:

1 - aortic prosthesis,

2 - duplication of the aortic prosthesis (“skirt”),

3 - vascular clips.

Fig. 2 shows a diagram of fixation of the descending aorta with a prosthetic “skirt”, where:

1 - aortic prosthesis,

2 - duplication of the aortic prosthesis (“skirt”),

3 - vascular clips,

4 - descending aorta.

The method is carried out as follows (Fig. 1, Fig. 2) After initiating circulatory arrest, the lumen of the aortic arch is opened and the zone of the distal aortic anastomosis is prepared for anastomosing with a multi-branch aortic prosthesis 1. The descending aorta 4 is revised and the appropriate size of the multi-branch aortic prosthesis is selected for implantation. Then, the multi-branch aortic prosthesis is corrugated in the transverse direction with the formation of a duplicate of the aortic prosthesis - the prosthetic "skirt" 2. After which, vascular clips 3 are applied along the entire circumference of the formed prosthetic "skirt" 2. Then, a distal aortic anastomosis is formed between the multi-branch aortic prosthesis 1 and the descending aorta 4, passing the threads through the prosthetic "skirt" 2. As the distal aortic anastomosis is applied, vascular clips 3 are removed, after which other sections of the thoracic aorta are reconstructed.

Clinical example

Patient K., 65 years old, was admitted to the cardiac surgery hospital with the diagnosis: Aneurysm of the aortic arch and descending aorta, confirmed by echocardiography and CT with contrast. It was decided to perform reconstruction of the aortic arch using the "elephant trunk" technique.

The main stage of the operation proceeded in the following sequence. After performing sternotomy, the ascending aorta and aortic arch were isolated. The brachiocephalic trunk and right atrial appendage were cannulated to connect the artificial blood circulation machine. After cannulation, the patient was cooled to a body temperature of 28°C. Upon reaching the target temperature, circulatory arrest with unilateral perfusion of the brain was initiated. The multi-branch aortic prosthesis was corrugated in the longitudinal direction to form a duplication - a prosthetic "skirt", vascular clips were applied to the prosthetic "skirt" along the circumference of the prosthesis. After opening the lumen of the aortic arch, it was prepared for forming a distal aortic anastomosis with the multi-branch aortic prosthesis. A multi-branch aortic prosthesis was antegradely inserted into the descending aorta to a depth of 10 cm. After positioning it at the required depth, a distal aortic anastomosis was formed through the prosthetic "skirt" with the multi-branch aortic prosthesis, and the vascular clips were removed as the anastomosis was formed. Thus, the formed distal aortic anastomosis did not require additional suturing of questionable areas due to its sufficient sealing, which reduced the time of the anastomosis and the time of circulatory arrest to 18 minutes. Then, reconstruction of the supra-aortic vessels was performed. Artificial circulation was resumed with the calculated perfusion rate. A proximal aortic anastomosis was formed at the level of the sino-tubular junction. The operation was completed with wound drainage, metal osteosynthesis of the sternum and layer-by-layer wound suturing.

The operation was completed in a standard manner. The duration of artificial circulation was 100 minutes, the time of cardiac arrest was 81 minutes, the time of circulatory arrest was 18 minutes. The patient was transferred to the intensive care unit.

The patient regained consciousness 10 hours after the operation. Neurological status without focal symptoms of the brain and spinal cord. The amount of hemoglobin, erythrocytes and platelets in the postoperative period was satisfactory and did not require transfusions for replenishment. The patient was on artificial ventilation for 12 hours. The total time of the patient's stay in the intensive care unit was 2 days. According to the data of spiral computed tomography of the aorta with contrast in the postoperative period, all anastomoses are passable and hermetic. The patient was discharged from the hospital in a satisfactory condition on the 14th day after the operation.

The method was tested on 10 adult patients. Preparation for surgery and anesthetic care were the same for all patients.

The use of the proposed method made it possible to quickly form a distal aortic anastomosis with its reliable fixation and sealing.

Literature

1. Borst H.G. The elephant trunk operation in complex aortic disease. Current opinion in cardiology. 1999; 14: 427-431.

Claims (1)

A method for forming a prosthetic "skirt" of a multi-branch aortic prosthesis when performing a distal aortic anastomosis during the "elephant trunk" procedure, characterized in that the multi-branch aortic prosthesis is first corrugated in the transverse direction with the formation of a duplication along the entire circumference of the multi-branch aortic prosthesis, vascular clips are alternately applied to the formed duplication and a prosthetic "skirt" is created, then the multi-branch aortic prosthesis is placed in the descending aorta, positioned at the required depth and a distal aortic anastomosis is formed with the created prosthetic "skirt" with sequential removal of the clips from the multi-branch aortic prosthesis.