RU2452401C2 - Method of microvascular anastomosis formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to vascular surgery. One fixing suture is applied on both donor and recipient vessels in lateral walls of vessels. After that, on the wall of recipient vessel performed is transversal cut with size 2-3 mm × 0.5-1.0 cm above anastomosis zone. Through said cut catheter provided with strent is introduced into vessel lumen. Stent is guided into lumen of donor vessel in such a way that half of stent is in donor vessel, and half is in recipient vessel. Catheter is removed ensuring stent extension with its opening under the impact of vessel lumen. Vessels in anastomosis zone are fixed with interrupted sutures, 2-3 suturess are applied in area of performed transversal cut.

EFFECT: method makes it possible to ensure contact of vessels with homogeneous layers on anastomosis line; absence of anastomised vessels of muscular envelope or adventitial cover in lumen; smoothness of vessel surface in anastomosis zone and absence of bends; to prevent injuries in anastomosis area and along vessel length due to absence in stent of perforating as well as cutting ability; to avoid contact of blood passing through vessel with threads; to support specified diameter of vessel lumen, which facilitates normal blood flow in place of connection; to provide possibility of applying even both in thickness and in distance from vessel edge, stitches; to ensure reduction of time of anoxia of vessel and fed by it tissues due to reduction of surgery time.

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Description

The invention relates to medicine, namely to surgery, and can be used to form a microvascular anastomosis, in particular during autologous transplantation.

A number of methods are known from the prior art for the formation of anastomoses between vessels. So, for example, there is a known method of forming a microanastomosis of blood vessels, characterized in that one end of the vessels to be connected is applied to the other end and the ends of the walls of the ends of the vessels joined to each other are sewn together using metal micro-brackets (RU 94046363 A1, 10.27.1996). The technical result achieved by the implementation of the methods of the proposed method is the possibility of restoring the patency of blood through the connected vessels. However, the known method is highly traumatic, can lead to thrombosis, requires a tight comparison of the ends of the vessels to each other before applying brackets, which is not always technically feasible.

The prior art also known a method of seamlessly applying an anastomosis to blood vessels by using a device made in the form of a ring with a ring holder on one of its ends. At the other end, the ring has pointed teeth evenly spaced around the circumference. The teeth serve as hooks for stringing and pressing the ends of the vessels to the ring. The free ends of the vessels are connected and fixed on the ring with a ring holder on one of its ends. The end of the vessel of smaller diameter is introduced into the hole of the ring on the opposite side of the end with pointed teeth. They pull it through the ring, flang it around the entire circumference of the ring and string it onto the teeth. The end of a large-diameter vessel is brought to the teeth and strung on them, after which the teeth with the strung ends of the vessels are pressed to the ring (RU 2365348 C1, 08.27.2009). The technical result of the known method is to increase the reliability of fixation and tightness of the anastomosis, ensuring reliable patency in the smallest arteriole. However, this method also has several disadvantages: for example, due to the fixation of the vessel by the pointed curved teeth of the ring, conditions are created for the formation of blood clots; in addition, the process of installing a ring and connecting vessels in practice does not exclude the occurrence of deformation, corrugation, eruption of the vessel wall, especially when connecting small-caliber vessels.

In addition, the prior art method of connecting vessels using a screw-in device (RU 2329774 C2, 07.27.2008), which allows the anastomosis to connect the lateral parts of two vessels (side-by-side) or the end of one vessel with the side of another vessel (end-to-side) without suturing. The disadvantage of this method is the impossibility of applying an anastomosis between vessels end-to-end.

Closest to the proposed method is a method of forming a microvascular anastomosis by introducing into the lumen of the vessel a cylindrical rod made with a rounded end and provided with a surface in the form of a truncated cone with a flat and a longitudinal guide groove under the needle (SU 1777838 A1, 11/30/1992). The truncated cone and the rounded end make it easy to insert the device into the lumen of the vessel, and the longitudinal guide groove located on the flat allows the needle to be injected perpendicular to the vessel wall. The disadvantages of this method are that the cylindrical rod proposed for introduction has a diameter of 0.2 to 4 mm, which allows it to be used only when stitching vessels of a certain diameter; the introduction of a cylindrical rod into the lumen of the vessel is accompanied by an intima injury, which subsequently leads to a change in the lumen of the vessel (its deformation), thrombosis.

Our proposed method is aimed at overcoming all of the above disadvantages through the use of a self-expanding stent for fast and reliable connection of blood vessels end to end.

A stent is a tubular skeleton of a rather low profile that opens inside the vessel. In the opened state, the frame supports the vascular wall, preventing it from subsiding and providing full blood flow. The stent is composed of wires, the thickness of the wire does not exceed 0.125 mm, the length is up to 25-30 mm, and the diameter in the expanded state is 2.5-4.0 mm. Before use in the anastomosis, the stent is inserted inside the catheter or conductor in a non-flattened form, when stenting in the lumen of the vessel, it opens (Fig. 1)

The technical result achieved by the implementation of our proposed method is:

- ensuring the contact of blood vessels with homogeneous layers - intima and intima - along the line of the anastomosis;

- the absence in the lumen of the anastomosed vessels of the muscle membrane or adventitious cover;

- ensuring a smooth surface of the vessel in the area of the anastomosis (lack of kinks);

- the absence of damage in the anastomosis and throughout the vessel due to the lack of perforating as well as cutting ability in the stent;

- ensuring the absence of contact passing through the vessel of blood with threads;

- maintaining the lumen of the vessel of a given diameter (the diameter of the stent), which contributes to the normal blood flow at the junction;

- providing the ability to impose uniform, both in thickness and in distance from the edge of the vessel, stitches;

- providing a reduction in the time of anoxia of the vessel and tissues fed by it by reducing the time of intervention.

All of the above leads to a significant increase in the effectiveness of our proposed method compared to previously known ones, a decrease in the number of complications after anastomosis is applied (maintaining the lumen, the absence of thrombosis, a decrease in the severity of the inflammatory reaction from the intima of the vessel), and a decrease in the invasiveness of the intervention.

The method is as follows.

We divided the formation of a microvascular anastomosis using a vascular stent into 3 stages.

At the first stage, vessels are isolated using methods widely used in vascular surgery. Vessels are distinguished, between which an end-to-end anastomosis will be applied with a length of at least 1.0 cm each (a vessel transplanted into the donor zone is called a donor, and the other is recipient). Under optical magnification, an audit is made of the inner lumen of the vessel to assess the state of intimacy. Perfusion of the lumen of the vessel with a solution of 0.9% sodium chlorine.

At the second stage, a thread with a thickness of 8.0-10.0 (depending on the thickness of the walls of the vessels) imposes one fixing suture in the side walls of the vessels, for a total of 2 seams on each of the vessels. These sutures allow contact between the ends of the vessels, play the role of holders during stenting of the lumen of the vessels and ensure the reliability of the anastomosis.

In the third stage, a transverse incision of 2-3 mm in size is 0.5-1.0 cm above the anastomotic zone on the wall of the recipient vessel. A catheter (conductor) equipped with a stent is inserted through this incision into the lumen of the vessel. The size of the stent is chosen taking into account the diameter of the vessel (they must correspond), and the diameter of the catheter must be smaller than the diameter of the vessel (by enough to ensure atraumatic insertion of the catheter into the lumen of the vessel). Slowly pressing the rod of the catheter directs the stent into the lumen of the donor vessel so that half of the stent is in the donor vessel and half in the recipient.

Then the conductor is removed, which leads to the expansion of the stent with the opening under its influence of the lumen of the vessels. After that, the relative position of the vessels using optical magnification is re-evaluated. After assessing the mutual position of the vessels in the anastomotic zone, several nodal sutures will be applied. A 2-3 suture is applied in the area of the transverse incision.

The proposed method is illustrated by the following clinical example.

Example 1. Patient B ,, 62 years old, was undergoing treatment in the department of microsurgery MNII them. P.A. Herzen, with a diagnosis of Stage III larynxopharyngeal cancer, T3NxM0, condition after chemoradiotherapy in 02/01/2009 (SOD 36 Gy) and surgical treatment on 05/05/2009.

During the follow-up examination, no data were found for relapse and metastases, and the patient turned to P.A. Herzen Moscow Scientific Research Institute for Rehabilitation and was hospitalized in Dep. microsurgery.

Upon receipt: Condition is satisfactory. Complaints about the orostoma. The face is symmetrical. Against the background of postoperative changes, focal and infiltrative changes were not detected. Lymph nodes of the neck are not detected.

Fibrolaryngoscopy: condition after laryngopharyngectomy. On the lines of resection - without signs of relapse.

According to ultrasound of the neck, thyroid gland, regional areas, liver, abdominal cavity, retroperitoneal space - scar-inflammatory changes in the neck along the vessels along both sides without focal zones.

September 3, 2009. Operation: Delayed pharyngoplasty with an enteric flap, autodermoplasty, lymphadenectomy on the left neck.

Under endotracheal anesthesia, a skin incision was made on the antero-lateral surface of the neck on the left. The skin flap is separated and set aside. During the audit, metastatically changed l / nodes were not identified. According to the technique adopted in the department, a left-sided lymphadenectomy was performed with preservation of the left accessory nerve and isolation and ligation of the thoracic duct. After that, the left upper thyroid artery and vein are isolated, mobilized and prepared for anastomosis. Performed the mobilization of tissues of the root of the tongue and pharynx along the perimeter, mobilization of the mouth of the esophagostoma. Next, a paraumbilical incision was made on the anterior abdominal wall. Minilaparotomy performed. Using a video-assisted revision of the abdominal organs, no tumor pathology was detected. Using an endoscopic technique under video-assisted control, the formation of a small intestinal autograft was performed, including a third vascular arch of the mesentery of the small intestine, the leg length of which was 10 cm. The length of the small intestine transplant was 20 cm. The vascular leg was clipped and ligated. The small intestinal transplant was transferred to the area of the pharyngeal defect. Under optical magnification, the formation of microvascular anastomoses between the mesenteric artery and a vein with an upper thyroid artery and a vein on the left. At the first stage, using the microsurgical technique, an audit of the inner lumen of the vessels was performed to assess the state of intimacy. Perfusion of the lumen of the vessel with a solution of 0.9% sodium chlorine was performed. At the second stage, a thread with a thickness of 8.0 imposed fixing seams in the side walls of the vessels, for a total of 2 seams on each vessel. At the third stage, a transverse incision was made on the upper wall of the superior thyroid artery - arteriotomy, at a distance of 1 cm above the zone of the planned anastomosis, 3 mm in size. A catheter (conductor) equipped with a stent is inserted through this incision into the lumen of the vessel. Then, slowly pressing the rod of the catheter, the stent is directed into the lumen of the vessel so that half of the stent is installed in the donor vessel, and the other half in the recipient. After installing the stent, the catheter guidewire was removed, which led to the expansion of the stent with the opening of the vascular lumen under its influence. After assessing the mutual position of the vessels, they were fixed with interrupted sutures. Also, 2 sutures were applied to the area of arteriotomy (transverse section). The formation of a venous anastomosis was performed by a similar technique. The start of blood flow. The flap is viable. Further, according to the technique adopted in the department, the pharyngeal-small intestinal and small intestinal-esophageal anastomoses were superimposed. Installed nasogastric tube. An inter-intestinal anastomosis is applied between the previously resected small intestine of the end-to-end type. The abdominal cavity is closed tightly, leaving drainage in the intestinal anastomosis. Layered seams on the neck wound leaving rubber graduates in the subglottis. The defect of the skin of the neck was restored by autodermoplasty with split dermis from the right thigh. Toilet wounds. Produced toilet wounds.

During the immediate postoperative period without complications, planned infusion, rheological and antibacterial therapy was carried out. The engraftment of the flap is complete. A good functional and cosmetic effect has been achieved. On 20 days after surgery in satisfactory condition, the patient was discharged from the department. The following is a clinical example, confirming the need to strictly adhere to the techniques of the proposed method, as well as the sequence of their implementation in order to implement the stated purpose and achieve the above technical result. That is, an example that demonstrates that any change in the proposed methodology will not allow us to obtain the above technical result, but will lead to complications.

Example 2. Patient M ,, 57 l., Was treated in the department of microsurgery MNII them. P.A. Herzen, with a diagnosis of Chondrosarcoma of the upper jaw on the right IB Art. T2N0M0G-2. Condition after combined treatment 02-03.2009. No relapse and metastasis.

During the follow-up examination, no data were found for relapse and metastases, and the patient turned to P.A. Herzen MNIIO for rehabilitation and was hospitalized in Dep. microsurgery.

Upon admission: satisfactory condition. Food through a nasogastric tube. The right half of the upper jaw is removed. Locally without evidence of tumor recurrence. Ptosis of the right eyeball due to the resected lower wall of the orbit. Lymph nodes of the neck are not enlarged.

When a two-time histological examination of tissues from the edges of the resected upper jaw No. C 6859/6, C 25477-79 / b - granulation tissue.

R-lungs: without focal and infiltrative shadows.

Ultrasound: the lymph nodes of the neck are not changed. In the abdominal cavity without tumor pathology.

CT of the facial skeleton: in the area of operation without signs of tumor recurrence.

In terms of rehabilitation, the operation was performed on September 29, 2009: delayed microsurgical plasty with a musculoskeletal flap using an ilium crest on the left, upper jaw on the right, tracheostomy.

Under endotracheal anesthesia, a skin incision was made parallel and 1.5 cm higher than the right inguinal ligament and above the anterior iliac spine on the left. Dissected subcutaneous fat, aponeurosis of the anterior-lateral parts of the abdominal wall, the external and internal oblique muscles of the abdomen. A vascular pedicle of the flap, deep envelopes of the ileum of the artery and vein, to the places of their departure from the external iliac artery and vein, was found and isolated throughout the vascular leg. Further, according to the accepted method, a bone-muscle-skin autograft was formed with the inclusion of an ileal crest 5 × 5 cm and fibers of the external and internal oblique muscles of the abdomen with a feeding leg — deep envelopes of the ilium by an artery and vein, a skin area of 5 × 3 cm in size. . The iliac wing resection line is waxed. Next, the old postoperative scars were excised along the edge of the upper jaw defect on the right. The left facial artery and vein are isolated, mobilized and prepared for anastomosis. The formed musculoskeletal skin flap is cut off and transferred to the area of the head defect on the right, the vascular leg of the flap is passed through the tunnel. Under optical amplification, the creation of microvascular anastomoses between the left facial artery and vein and the right deep envelope of the iliac artery and vein was accomplished. Using microsurgical technique, the internal lumen of the vessels was revised, the lumen of the vessel was perfused with isotonic solution. Performed the formation of arterial anastomosis using a vascular stent of the type "end-end". An arteriotomy was formed on the wall of the facial artery and a catheter (guide) was inserted through this incision, equipped with a stent in the lumen of the vessel. The catheter was inserted into the donor vessel with difficulties arising from the absence of previously applied sutures in the vessel walls. Due to difficulties, only about a third of the stent was in one vessel, and two-thirds in another. The catheter guide was removed, which led to the straightening of the stent with the opening of the vascular lumen under its influence. Nodal microsurgical sutures were applied in the anastomosis zone. The formation of a venous anastomosis was performed by a similar technique. The start of blood flow. After 15 minutes, during the control examination, arterial insufficiency of the flap was revealed; during the audit, a thrombus was found located at the entrance of the stent in the artery of the graft vascular leg. Resection of the anastomosis and stent removal, thrombectomy with resection of the artery feeding the leg for 1 cm were performed. Access was made in the lower third of the forearm along the medial surface. An autoarterial graft from the radial artery was taken. The donor wound is sutured in layers. A microvascular arterial anastomosis was formed between the facial artery, the arterial insert and the deep ileal envelope of the ilium artery with a flap of the end-to-end type. The start of blood flow. After 5 minutes, the viability of the flap is restored. The anastomotic zone and the subglottis are drained by latex graduates. Treatment of wounds with antiseptic solutions. Aseptic dressings.

The course of the postoperative period was complicated by partial necrosis of the flap (the skin area of the flap was necrotic). A necrectomy was performed. The further course of the postoperative period is smooth. The flap has taken root. The wounds healed by primary intention. The seams are removed. On the 10th day of the postoperative period, decanulation was performed. In satisfactory condition, the patient was discharged from the hospital.

Claims (1)

A method of forming a microvascular anastomosis, including the allocation of donor and recipient vessels and introducing into the vascular lumen an auxiliary device for forming an anastomosis, characterized in that after assessing the state of intima, a total of 2 sutures are placed on the donor and recipient vessel in one fixative suture in the lateral walls of the vessels on each of the vessels, then on the wall of the recipient vessel, a transverse incision of 2-3 mm is made 0.5-1.0 cm above the anastomosis zone; through this incision, a catheter equipped with a stent is inserted into the lumen of the vessel; slowly pressing the catheter shaft, the stent is guided into the lumen of the donor vessel so that half of the stent is in the donor vessel and half in the recipient; the catheter is removed, providing a straightening of the stent with the opening under its influence of the lumen of the vessels; after assessing the mutual position of the vessels using optical magnification, several nodal sutures are applied in the anastomotic zone; impose 2-3 seams in the area of the transverse incision.

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