Method of treating venous hypertension syndrome of upper limb and brain accompanying brachiocephalic vein occlusion associated with arteriovenous fistula. RU patent 2513475.
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FIELD: medicine.
SUBSTANCE: neck is incised. Two incisions are made: one is 5 cm long on the side of an occluded brachiocephalic vein in an infraclavicular fossa 1 cm below a clavicle parallel therewith with a cephalic vein separated through 4-5 cm. The second incision is 4 cm long and extends on the neck on the opposite side along a front edge of a sternocleidomastoid muscle. An anterior jugular vein is separated from a jugular notch in the cranial direction through 4 cm. The anterior jugular vein is clamped within the jugular notch, and a longitudinal venotomy being 3 cm long is started 4 cm above. That is followed by creating an anastomosis of the anterior jugular vein with a funnel-shaped prosthesis cuff made of spiral-reinforced polytetrafluoroethylene. The prosthesis is placed top to bottom towards a lower edge of the wound; the prosthesis is brought subcutaneously using a short tunnelling device, arch-wise into the subclavicular wound. A cephalic vein is clamped within a subclavicular vein inflow, and a longitudinal cephalic venotomy 2-3 cm long extends 4 cm in the distal direction, and an anastomosis of the prosthesis and cerebral vein is created.
EFFECT: method enables reducing invasiveness and arresting the venous hypertension syndrome of the upper limb and brain.
2 ex, 7 dwg
The invention relate to medicine, namely to surgery and may be used in the treatment of syndrome venous hypertension of the upper limb and brain occlusion brachiocephalic veins associated with arteriovenous fistula.
Most often occlusive pathology brachiocephalic veins are common in patients with end-stage chronic renal failure (DPN), which is probably associated with more frequent and prolonged use of catheters in this population group. It is believed that eventually stenosis main veins occurs in 40% of patients who underwent catheterization brachycephalic veins. Pathophysiology is not entirely clear, but probably repeated and lengthy injury due to an increase in the volume and speed of blood flow, cause hyperplasia neointima. As a rule, the disease is asymptomatic, however, if in the affected pool operates arteriovenous fistula (AWF), venous hypertension may show swelling of the hands and neofunctionalist vascular access.
Conducting good hemodialysis, adequate blood purification, essentially depends on the quality of access to the circulatory system of the patient. Since Brescia and Cimino first described a new and reliable method of formation of arteriovenous fistula (AWF) [1], have been proposed and tested, numerous variants of formation of the vascular access. The number of patients who need kidney dialysis, is growing every year, increasing their life expectancy. Limited resources for establishing vascular access forces surgeon to the development of surgical techniques for the preservation of existing accesses as long as possible. Venous hypertension after the formation of arteriovenous fistula, or arteriovenous shunt, approximately 10-15% of cases [2,3]. For this reason, the maintenance, preservation and restoration of vascular access for software hemodialysis is an actual problem of vascular surgery and Nephrology. Irrational tactics of formation and use of permanent vascular accesses entails rapid depletion of vascular resource patient. This, in turn, results in inadequate hemodialysis and rapid decompensation of the patient.
The first attempts of prosthetics top Vena cava in the experiment were taken in 1898 C.Gluck Many years of searching the solution of recovery tasks of venous outflow in the system of the upper Vena cava showed that reconstructive surgery to maintain, or restore, the Central venous blood flow can effectively arrest the swelling and to ensure the preservation of AWP [4].
As a prototype of the selected method of cross-bypass proposed in the dissertation Omarova HP in 2010[5], in which one of the longitudinal incision in the neck distinguish the external jugular vein at the side opposite occlusion, and cross the cranial end of the places of formation. Allocate venous angle by occlusion, the cranial end of the external jugular vein subcutaneously fail to venous corner and formed anastomosis according to the type "end to side". To prevent excess of the shunt, and his extravasal compression used spiral A.N. Vedeno. The method used traumatic access in the allocation of venous corner. The selection and crossing the external jugular vein, with resetiranje and ligation of its tributaries, in patients with venous hypertension of the brain leads to deterioration of venous outflow from the head. When the shunt thrombosis, due to a confluence of external jugular veins in the main vein (venous angle or subclavian vein), high risk of thromboembolic complications. With the defeat of the subclavian vein, and/or venous angle, due to the limited length of Vienna, the operation is impossible.
Purpose the proposed invention is mild syndrome venous hypertension of the upper limb and brain, occlusion brachiocephalic vein (BCV)associated with arteriovenous fistula, creation of bypass grafting from the pool affected BZW in the pool intact BZW using minimally invasive way.
The method of treatment of a syndrome of venous hypertension of the upper limb and brain occlusion brachiocephalic veins associated arteriovenous fistula, involves an incision in the neck, highlighting the jugular vein, venatorio, formation of the anastomosis. Perform two sections: the first - on the side of the occluded brachiocephalic vein, subclavian hole 1 cm below the collarbone, and parallel to it, length 5 see Allocate head Vienna during 4-5 see A second incision perform on the neck, on the opposite side from the jugular notch on the front edge of the sternocleidomastoid muscle, length 4 see Allocate front jugular vein from the jugular notch in cranial direction, over 4 see Then compress the front jugular vein in the field of the jugular notch, and 4 cm above it. Produce longitudinal venatorio 3 cm length, after which form the anastomosis front jugular vein with funnel-shaped cuff prosthesis PTFE reinforced by spiral. This prosthesis come from above downward towards the lower edge of the wound, spend his short tunnellers subcutaneously, arched into the wound subclavian region, pinch the head of Vienna in the area of confluence into the subclavian vein, and 4 cm distally. Produce longitudinal venatorio head of Vienna in length, 2-3 cm form the anastomosis of the prosthesis and the head of Vienna.
The cut in the subclavian hole on the side of the occluded brachiocephalic vein, parallel to the collarbone, 1 cm below her, length 5 cm, made so that the medial border of the wounds were located on the middle clavicle, emitting head of Vienna during 4-5 cm, and a second incision on the opposite side of the neck, on the leading edge of the sternocleidomastoid muscle, from the jugular notch, over 4 cm, emitting front jugular vein, from the jugular notch in cranial direction, over 4 cm, provides miniinvasive surgical intervention, because the veins are located under the superficial fascia, at a depth of 5-15 mm, which ensures easy mobilization of Vienna and the possibility of surgery under local, or regional, anesthesia.
Clamping of the front jugular Vienna in the field of the jugular notch, and 4 cm above it, longitudinal venatoria 3 cm length, with the formation of the anastomosis front jugular vein with funnel-shaped cuff prosthesis PTFE reinforced by spiral, located from above downward towards the lower edge of the wound, provides optimization of hemodynamics in the anastomosis zone, preventing stagnation zones, reduces the intimal hyperplasia. Reinforced prosthesis excludes extravasal compression. Thrombosis described shunt, since there were many of the collateral branches of the venous system, the risk of thromboembolic complications is minimal.
The use of short tunneller for subcutaneous, arched conduct of the prosthesis into the wound subclavian region provides education subcutaneous tunnel right diameter in the right direction.
Clamping of the head of Vienna in the area of confluence into the subclavian vein, and distally by 4 cm lengthwise venatoria length of 2-3 cm, with the formation of anastomosis of the prosthesis and the head of Vienna, allows you to install short shunt, place the shunt so that the movements of the patient's neck and the shoulder-do not change the hemodynamics in it.
The method is illustrated in the above illustrations, where:
Figure 1 - shows the hands of the patient And. before surgery;
Figure 2 - flebogamma patient And. before surgery, where: 1 - head Vienna (v.cephalica), 2 - subclavian vein (v.subclavia), 3 - occlusion of the left brachiocephalic vein (v.brachiochalica);
Figure 3 shows the moment of operation: cross cefalica-front-jugular allisoncarolinet;
Figure 4 - the kind hands of the patient And. after surgery;
Figure 5 - color duplex scanning of cefalica-jugular bypass patient And. 10 months after the operation;
Figure 6 - flebogamma patient points to operations, where: 1 - head Vienna (v.cephalica), 2 - subclavian vein (v.subclavia), 3 - occlusion of the left brachiocephalic vein (v.brachiochalica), 4 - internal jugular vein (v. jugularis interna). 5 - front jugular vein (v. jugularis anterior); 6 - jugular venous arc (arcus venosus jugularis);
Figure 7 - flebogamma patient P. a month after the surgery, where: 1 - head Vienna (v.cephalica), 2 - front jugular vein (v. jugularis anterior); 3 - jugular venous arc (arcus venosus jugularis), 4 - shunt, 5 - right brachiocephalic vein (v.brachiochalica dextra)6 - superior Vena cava (v.cava superior).
The method is as follows.
The history of the development of the disease: a sick diabetes mellitus type II for 32 years, the last 7 years - insulin dependent. The patient developed diabetic nephropathy, chronic renal failure, terminal stage.
Since 2005, the patient on the software hemodialysis. Due to late diagnosis first hemodialysis sessions were held double barreled through the catheter into the left subclavian vein. In 2005 formed distal arteriovenous fistula (AWF) on the right. In 2007, due to thrombosis, AVF, the patient formed vascular access graft from polytetrafluoroethylene (PTFE) on the right forearm. In 2009 thrombosis AB prosthesis. Surgery: the formation of the vascular access autovenous grafts (v.saphena magna) on the right shoulder. Thrombosis in the early postoperative period. In 2009, the attempt of forming distal AWF on the left forearm was complicated by clots in the early postoperative period. In 2009, the patient was installed permanent catheter into the left subclavian vein. In June 2011, made the formation of the proximal AWF on the left shoulder. In the postoperative period is marked swelling of the left hand.
Objectively, on arrival expressed intense swelling of the left upper limb (volume shoulder - 74 cm, forearm - 43 cm), dark figure on the arm and the left side of the chest as "head of Medusa". Over auf systolic murmur, because of the apparent swelling be palpated, or puncturevine, for hemodialysis impossible. For comparison: the shoulder of the right hand of around 30 sm, forearm - 21 cm (see figure 1).
According to the U.S. veins in the upper extremities
Left: ABF (brachial artery anastomosis and the head of Vienna) on the shoulder functions. Head Vienna, shoulder, armpit, subclavian vein - passable, blood mixed (arterio-venous). Internal jugular vein is passable, venous blood flow.
Right: saphenous vein occluded. Shoulder, armpit, subclavian vein passable.
15.07.12 held phlebography, according to which revealed occlusion of the left nameless Vienna and the mouth of the left subclavian vein. Of x-ray endovascular recanalization not possible (see Fig 2).
With the purpose of preservation of native AV fistula left shoulder and unloading left hand made a decision on carrying out extracuricular bypass from the basin of the left brachiocephalic vein in the pool right of Vienna.
According to the U.S. in the field of the jugular notch collarbone nazirovna right front jugular vein (v.jugularis anterior) 3 mm in diameter, shunting through the jugular venous arc and right external jugular vein. Anastomosis with the Vienna offers the following advantages: 1. Small length of the shunt, which is important for reconstruction of varicose veins. 2. Motion in the shoulder and neck not create extravasal hemodynamic disturbances. 3. In the case of thrombosis of the shunt, the risk of thrombosis main veins on the right is much lower than in the case of formation of anastomosis subclavian or jugular vein.
27.07.11, under endotracheal anesthesia, surgery was performed: Cross of cefalica-jugular allisoncarolinet (PTFE "Dataflo" 7 mm) from left to right (see figure 3).
In the postoperative period there was observed positive dynamics: significantly decreased swelling of the left upper extremity. On the 7th day after operation arm circumference was 47 cm, forearm - 28 see
4.08.2011, was successfully held hemodialysis session through auf left shoulder.
05.08.2012, the patient was discharged with improvement of a condition for further outpatient program hemodialysis through auf left shoulder.
The patient is observed within 10 months after the operation. Clinically: 10 months swelling of the left upper limb is completely stopped, the circumference of the left shoulder 32 cm, forearms - 22 cm (see figure 4).
According to UI: shunt operates at the speed of blood flow to 70 cm/s (see figure 5).
Hemodialysis is carried out through the native auf left shoulder with a speed of 300 ml/min, pressure upon venous return 200 mm Hg
Clinical example 2
Patient p, 1946 of a birth, was on treatment at the departments of Nephrology and vascular surgery №1 of the Republican clinical hospital in Kazan with 27.03.2012, 07.04.2012, he started as planned. Complaints of headache, tension in the head, oedema of the left half of the face and neck, mild swelling of the left hand, aneurysmal expansion of AWP left shoulder.
Objective: swelling of the left half of the face and neck, pastoznost left hand, aneurysmal expansion and tortuosity of AWP left shoulder, over auf systolic murmur, pulsation of the main arteries saved, the possibility puncture auf not violated.
28.03.12 held venography: pyloric stenosis v.cephalica to 70%, occlusion of the left brachiocephalic vein (see Fig.6).
According to the U.S. from 01.04.12,: pyloric stenosis v.cephalica, the expansion of the left subclavian vein up to 2 cm, with speeds up to 250 cm/s, retrograde blood flow in the jugular and vertebral veins.
According to raamatulevi (3.04.12): signs of venous hypertension left, asymmetry factor the 122.7%.
04.04.2012, under regional anaesthesia, surgery was performed: cross cefalica-jugular allisoncarolinet (PTFE "Dataflo" 7 mm) from left to right.
In the postoperative period there was observed positive dynamics: swelling of the face and neck slept on the 2nd day after the operation, were headaches and tension in the head.
According to reoentsefalografii (09.04.12): venous outflow in the normal range, the asymmetry factor of 33%
According to the U.S.: the diameter of the left subclavian vein decreased to 16 mm, the blood flow in the left vertebral artery was antegrade, the jugular veins remains retrograde blood flow, but with reduced speed of 50 cm/S.
Sources of information
Treatment of venous syndrome hypertension upper limbs and brain occlusion brachiocephalic veins associated arteriovenous fistula, including a cut in the neck, highlighting the jugular vein, venatorio, formation of anastomosis, wherein perform two sections: the first - on the side of the occluded brachiocephalic vein into the subclavian hole 1 cm below the clavicle and parallel to it, length 5 cm, allocate head Vienna during 4-5 cm, a second incision perform on the neck, on the opposite side on the leading edge of the sternocleidomastoid muscle length of 4 cm, allocate front jugular vein from the jugular notch in cranial direction, over 4 cm, and then compress the front jugular vein in the field of the jugular notch, and 4 cm above it, produce longitudinal venatorio 3 cm length, after which form the anastomosis front jugular vein with funnel-shaped cuff prosthesis of PTFE reinforced by spiral, with the prosthesis come from above downward towards the lower edge of the wound, spend his short tunnellers subcutaneously, arched into the wound subclavian region, pinch the head of Vienna in the area of confluence into the subclavian vein, and 4 cm distally, produce longitudinal venatorio head of Vienna in length, 2-3 cm form the anastomosis of the prosthesis and the head of Vienna.