Method for integrated treatment of acute thromboembolia of pulmonary artery

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely angiology, intensive care, cardiovascular surgery and phlebology, and may be used for integrated treatment of acute thromboembolia of pulmonary artery. That is ensured by prescribing anticoagulants, disaggregants, antibiotic therapy added by thrombolytic therapy by the oral introduction of the preparation Thrombovasim 0.02 mg/kg combined with deobliteration of pulmonary artery or pulmonary trunk by direct surgical thromboembolectomy in complete bypass with retrograde perfusion of pulmonary arteries. Treatment of acute thromboembolia is added by prescribing the preparation Vasaprostan* 60 mcg daily intravenously starting from the moment of diagnosing and up to 7 postoperative days.

EFFECT: method provides higher clinical effectiveness in the patients and preventing developing complications ensured by correction of main pathological links of developing complications of acute thromboembolia of pulmonary artery.

 

The invention relates to medicine, namely, angiology and intensive care, cardiovascular surgery and phlebology, and can be used for complex treatment of acute pulmonary embolism (PE).

Statistics in recent years both in Russia and abroad shows that a civilized society is losing hundreds of thousands of people due to development of acute pulmonary embolism: a case fatality rate is 30 to 45%, and an increase in the frequency of pulmonary embolism is becoming threatening [Nekrasov Û.F., H. beavers, Osipov A.M., Antonov S.A. Acute pulmonary embolism. Methodological manual for doctors. SPb., 1996. - 25 S.].

Known methods of treatment of acute pulmonary embolism (PE), including thrombolytic therapy, invasive (non-surgical) methods, such as catheter embolectomy, and surgical embolectomy (with or without artificial circulation (IR).

The best results of treatment of massive pulmonary embolism obtained using surgical deobliteration pulmonary artery by direct embolectomy [Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy; a contemporary approach. Circulation 2002; 105:1416-1419. Yalamanchili K, Fleisher AG, Lehrman SG, Axelrod HI, Lafaro RJ, Sarabu MR et al. Open pulmonary embolectomy for treatment of major pulmonary embolism. Ann Thorac Surg 2004; 77:819-823. Dauphine C, Omari B. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Thorac Surg 2005; 79:1240-1244. Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005; 112:28-32. Leacche M, Uic D, Goldhaber SZ, Rawn JD, Aranki SF, Couper GS, et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005; 129: 1018-1023].

The lack of direct surgical embolectomy is [Albertine PHD, Wiener-Kronish JP, K. Koike engineering Germany, N.C. Staub Quantification of damage by air emboli to the lung microvessels in anesthetized sheep. J Appl Physiol 1984; 57:1360-1368. Wang D, Li MH, Hsu K, Shen CY, Chen HI, Lin YC. Air embolism-induced lung injury in isolated rat lungs. J Appl Physiol 1992; 72:1235-42. Huang KL, Lin YC. Activation of complement and neutrophils increases vascular permeability during air embolism. Aviat Space Environ Med 1997; 68:300-5. Kuhn M, Fitting JW, Leuenberger P. Acute pulmonary edema caused by venous air embolism after removal of a subclavian catheter. Chest 1987; 92:364-365. Fitchet A, Fitzpatrick AP. Central venous air embolism causing pulmonary oedema mimicking left ventricular failure. BMJ 1998; 316:604-606. Boer WH, Hene RJ. Lethal air embolism following removal of a double lumen jugular vein catheter. Nephrol Dial Transplant 1999; 14:1850-1852. Kapoor T, Gutierrez G. Air embolism as a cause of the systemic inflammatory response syndrome: a case report. Crit Care 2003; 7:98-100]:

1. the inability of embolectomy out of small branches LA,

2. the impossibility of simultaneous surgical intervention and systemic thrombolysis,

3. experimental and clinical data indicate the development of air embolism LA arising from thromboembolectomy that induces the release of endothelial cytokines, which in turn cause damage to the microvascular LA and pulmonary parenchyma, leading to complications and death.

The aim of the invention is to increase the effectiveness of treatment Bo is lnyh with pulmonary embolism (PE) and prevention of complications.

This goal is achieved through improvement microsimulating channel of the lung parenchyma by assigning intravenous drugs prostaglandin series, for example Vazaprostan®a daily dose of 60 mcg.

The introduction of the drug carried out intravenously since the diagnosis of pulmonary embolism in the preoperative period and up to 7 days in the postoperative period.

The drug Vazaprostan®is similar to the natural PgE1has vasodilator (at the level of arterioles, precapillary sphincter muscle of the arteries), antiplatelet and angioprotective action. Improves microcirculation and peripheral circulation, promotes the opening of collateral vessels. Improves blood rheology, increasing the elasticity of red blood cells and reducing the adhesion/aggregation of platelets. Possesses fibrinolytic effect. Affects the metabolism and increases utilization of glucose and oxygen, inhibits the release of free radicals and lysosomal enzymes from granulocytes and macrophages, stimulates protein synthesis, has a favorable effect on lipid metabolism (inhibiting the synthesis of cholesterol and reducing the concentration of LDL), inhibits the proliferation of smooth muscle cells. These known effects of the drug Vazaprostan®about navyvet its application in complex treatment of pulmonary embolism.

The method involves surgical benefits under endotracheal anesthesia in order to restore blood flow in the pulmonary artery is a direct open thromboembolectomy in conditions of artificial blood circulation and conduct retrograde perfusion LA. The implementation of the operational allowance is as follows.

Access to LA to produce an accepted way by performing a sternotomy.

Retrograde perfusion LA is used in conditions normothermal RJ with biovalley sinularia. Arterial line from the heart-lung machine is connected with a Y-shaped connector. One branch attached arterial cannula (which subsequently kanyoro the ascending aorta), the other is synthetic, perestou clip tube size 20 F, which kanyoro left atrium (through the right upper pulmonary vein, perestou a ligature). After the beginning of the IR pereginus the ascending aorta and perform cardioplegia. A longitudinal incision to expose the pulmonary trunk (distal to the valve of the pulmonary artery), the next section continues on the right and left main branches of LA. Thrombotic mass removed using surgical clamps and suction. Produce a revision of the right atrium and ventricle, remove all visible blood clots. Then (while LA is still open) remove the clamps on the left cannula and left preserv is filled with blood. After about 1 minute the blood begins to flow from the LA retrograde. Against this background, produce inflating lung ventilator for the most complete removal of thrombotic masses and air bubbles from distal branches of the LA. Clots and air bubbles aspiritual from LA. Then anteriormente hole is sutured, "left" cannula disconnect from the arterial line (Y-shaped connector) and used as drainage of the left atrium. Remove the clamp from the aorta and IR finish the generally accepted method.

To achieve complete removal of thrombotic masses of distal branches of the LA during thromboembolectomy patient in complex preoperative preparation include the appointment of a thrombolytic drug "Trombulak®" at a dosage of 0.02 mg/kg of the Drug Trombulak®" has the Thrombolytic effect associated with direct effects on fibrin and cellular mass of thrombus, anti-inflammatory and cytoprotective properties (patent RF №2213557), which justifies its use in complex therapy of pulmonary embolism.

Trombulak®increases fibrinolytic activity of the blood, providing a direct fibrinolytic action. The drug has a thrombolytic effect, the mechanism of which is associated with the direct destruction of the threads of fibrin, the arr is based on the basic framework of a blood clot. Trombulak®not reduces the level of fibrinogen, platelets, does not affect the coagulation time and duration of bleeding. Reduces the intensity of reperfusion damage, because it has anti-inflammatory and cytoprotective effect. Trombulak®not hydrolyzes native tissue proteins. The use of Thrombopathia®not contraindicated in the run-up to the operational manual and in the postoperative period.

In the complex treatment of pulmonary embolism, the technique is applied in 7 patients. The use of this method has greatly improved the results of complex treatment of pulmonary embolism.

The use of the proposed method in clinical practice revealed the following significant advantages over known methods of treatment of pulmonary embolism.

The combination of open thromboembolectomy and retrograde perfusion allows you to release all the arterial tree from thromboembolic masses.

Used in the treatment of drug Trombulak reduces the probability of rethrombosis in the field of surgery and repeated episodes of pulmonary embolism due to the impact on the primary focus of thromboembolism.

The method allows you to return to the workforce and to improve the quality of life of patients, as well as to enlarge the pool of patients previously midrange is remaining hopeless in the outcome of the surgical treatment.

The method of complex treatment of acute pulmonary embolism, including the appointment of anticoagulants, antiplatelet, antibiotic therapy and thrombolytic therapy, characterized in that thrombolytic therapy is carried out by introduction of oral thrombolytic drug "Trombulak" at a dosage of 0.02 mg/kg and complement deobliteration pulmonary artery or pulmonary trunk by direct surgical thromboembolectomy in extracorporeal circulation with conducting retrograde perfusion of the pulmonary arteries, complementing the comprehensive treatment of pulmonary embolism-drug Vazaprostan®a daily dose of 60 µg intravenously, starting from the moment of diagnosis and finishing the course of treatment on day 7 post-operative period.



 

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1 tbl

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1 ex

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2 ex

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25 cl, 8 tbl, 8 ex

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1 ex

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5 cl

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8 cl, 1 tbl

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