Article is addition to St. AORTIC ANEURYSM
Success achieved in the field of vascular surgery gives the chance to carry out radical treatment of aneurisms of any department of an aorta since the forecast for life at And. and. bad (apprx. 90% of patients perish in the next 2 years), operations are shown practically to all patients at whom the diagnosis is made And. and.
Localization of aneurism has a certain value for the solution of a question of indications to operation: at aneurisms of a ventral aorta of the renal arteries located lower than the level of an otkhozhdeniye, and aneurisms of a chest aorta of the indication to operation put more widely; at aneurisms of the ascending aorta and its arch, and also torako-abdominal aneurisms of surgical indication there are hl. obr. at threat of life of the patient (a possibility of a gap, fibrinferments, thromboembolisms).
Absolute indications to urgent intervention are ruptures of aneurism and stratification of an aorta.
Operations are contraindicated in the presence of heavy heart failure, at a renal failure and a liver.
Operations at And. and. can be palliative and radical. Palliative interventions are directed to prevention of a rupture of aneurism or to elimination of separate symptoms (pain, a dysphagy etc.). For this purpose enter the metal wire or drugs capable to cause thrombosis into a cavity of aneurism, shroud a wall of aneurism in synthetic fabric, make a diaphragmotomy or a decompressive sternotomy. Palliative operations in a crust, time are practically not made, except for an enveloping And. and. synthetic fabric at the menacing gaps in cases when there are absolute contraindications to performance of radical operation.
Radical treatment consists in a resection of the changed site of an aorta with the subsequent alloplasty.
All interventions apropos And. and. make under an intubation anesthesia.
Depending on an arrangement of aneurism operation is made or using artificial circulation (aneurism of the ascending and descending aorta and its arch), or with use of various methods of shunting. At interventions on an aortic arch sometimes combine artificial circulation with bypass shunting for ensuring blood supply of the head.
Aneurism of the ascending aorta
(fig. 1-3). Quick access - a longitudinal sternotomy. After opening of a pericardium and connection of the cardiopulmonary bypass allocate aneurism of the ascending aorta and on an aorta impose cross a clip proksimalny places of an otkhozhdeniye of branches of a brakhitsefalny trunk.
At artificial circulation with gradual cooling of blood to t ° 28-30 ° aneurism is opened with cross section, into mouths of both coronary arteries enter special cannulas for carrying out coronary perfusion. After that make a resection of the aneurism Defect of an aorta replace with allotransplant. In view of the fact that operation is carried out in the conditions of artificial circulation (heparinized blood), the transplant shall be impenetrable for blood.
In the beginning carry out a distal anastomosis of an aorta with a prosthesis, and then proximal. At this stage of operation correction of insufficiency of aortal valves can be in case of need made. After suture of the patient warm up to the usual temperature and continue artificial circulation until when the left ventricle is able to support blood circulation. Before mending of an operational wound the right mediastinal pleura is widely opened and establish drainages in the right pleural cavity and a pericardium.
In certain cases aneurism of the ascending aorta happens sacculate to rather narrow neck. Operation in such cases does not demand artificial circulation. Impose pristenochno a clip on a wall of an aorta at the basis of a neck of aneurism (fig. 4-6). The last is cut, and the neck of aneurism is taken in a number of continuous matratsny sutures with additional imposing on free edge of 8-shaped seams.
In some cases instead of artificial circulation the temporary bypass shunt from a plastic prosthesis can be used.
Aneurism of an aortic arch (fig. 7, 1). Operation demands broad access and is usually carried out from a left-side thoracotomy with slanting crossing of a breast and transition to the right side to the II—III mezhreberye.
Against the background of artificial circulation between the descending aorta and carotid arteries impose the bypass shunt by means of a plastic bifurcation prosthesis (fig. 7, 2).
Perfusion of vessels of the head is carried out in the retrograde way from the descending aorta. It is in rare instances possible to perfuse the right carotid artery retrogradno through the right subclavial artery. Further resect aneurism. Defect of an aortic arch is replaced with a prosthesis. The anastomosis of branches of an aortic arch with this transplant can be executed as separately for each vessel (with «transformation» left the general sleepy and subclavial arteries as if in the second anonymous artery), and with use of the general basis for mouths of all three brakhitsefalny vessels (fig. 7, 3). After implantation in a prosthesis of branches of a brakhitsefalny trunk carry out at first distal and then and proximal an anastomosis of an aorta with a prosthesis, and the temporary aorto-carotid bypass shunt prosthesis delete (fig. 7, 4).
The patient all this time is on artificial circulation.
Aneurism of a chest aorta
At operation is required protection of a spinal cord against the ischemia connected with crossclamping of an aorta. Apply various ways of shunting of blood: by means of the cardiopulmonary bypass or a plastic prosthesis.
The plastic shunt impose bypassing aneurism between sites of an aorta above and below it, on type the end sideways. After imposing of such shunt make excision of an aortic aneurysm.
Operation can be finished or substitution of defect of an aorta with other prosthesis on type the end in the end (then earlier imposed bypass prosthesis is removed, fig. 8 — 10), or the ends of the resected aorta sew up tightly, and the temporary bypass shunt remains constantly, having assumed a blood stream.
At traumatic aortic aneurysms and a number of inborn changes of the descending aorta usually apply imposing of the bypass extracorporal shunt from the left auricle in a femoral artery that at traumatic aneurisms quite often allows to recover an integrity of an aorta without use of a transplant since in these cases there is no loss of fabrics. The left-side side thoracotomy in the IV mezhreberye is made. Allocate an aorta in the field of the left subclavial and left general carotid artery above aneurism, and also the site of an aorta is lower than aneurism. Aneurism at this stage is allocated only partially. Further the bypass shunt (with the pump) from the left auricle in a femoral artery is installed. Protection of a spinal cord against ischemia requires only a half of that volume blood-groove on an aorta which is available in normal conditions. Further press an aorta distalny aneurisms, and open aneurism and exsect.
If at traumatic And. and. is available a complete circular separation of an intima and a mussel, an aorta on site of a gap completely cross and sew the end in the end through all layers. If the rupture of an intima and a mussel only partial, on a half of a circle, then is made a cross aortorrhaphy after a resection of aneurism. At impossibility to impose an anastomosis the end in the end defect of an aorta replace with a prosthesis (fig. 11 — 13).
Aneurism of a torako-abdominal aorta
Surgical access — a torakofrenolyumbotomiya. For preservation of a blood-groove on visceral branches of an aorta it is more preferable to use or a method of the bypass shunt prosthesis which impose the end sideways between a chest aorta above aneurism and a ventral aorta aneurisms (below renal arteries), or the shunt with the pump are lower (the left auricle — a femoral artery). Aneurism is excised, and visceral branches of an aorta (celiac, upper mesenteric, renal arteries) are in turn anastomosed on type the end in the end with lateral branches of a prosthesis shunt (fig. 14).
Aneurism of a ventral aorta
Almost in 90% of cases of an aneurysm is located below renal arteries, quite often extends also to bifurcation of an aorta.
Access — a median laparotomy from a xiphoidal shoot to a pubis. After opening of an abdominal cavity intestines are removed to the right, open a back leaf of a peritoneum, allocate the third department of a duodenum at plica duodenojejunalis. Allocate the left ileal artery and an ureter. Further allocate the lower mesenteric artery and cross it, at the same time the upper pole of aneurism is released. Sometimes it is necessary to leave a part of the lower mesenteric artery on aneurism. Further finally allocate proximal department of an aorta and the left renal vein. Examine ileal arteries and choose the place for future anastomosis with a prosthesis. It is desirable to keep an internal ileal artery to provide good blood supply of a sigmoid gut and cavernous bodies of a penis (prevention of impotence). Quite often it is necessary to choose the place of an anastomosis on an outside ileal artery. If it is struck with atherosclerotic process and is stenosed, then it is necessary to make the tunnel under an inguinal sheaf and to use a femoral artery for an anastomosis. The lower vena cava is separated from And. and. at first from above, in that place where there passes the left renal vein.
It is necessary to be afraid at the same time to injure the left ovarian or yaichkovy vein. If it lies very close to aneurism, it is better to tie up it and to cross. The abnormal double left renal vein can be accidentally injured, one of trunks a cut goes in depth, behind an aorta. After allocation of an aorta it is pressed above aneurism. Above a clip enter heparin into an aorta. Impose clips on ileal arteries. Below them enter 3 — 4 ml of divorced heparin (1 ml of heparin on 20 ml of normal saline solution).
As there are always unions of aneurism with a wall of the lower vena cava, there is no need to excise completely all aneurism. It is widely opened, delete pristenochny blood clots and an aneurysmal cup. The mouth of each lumbar artery on a back wall is stitched silk.
After a good hemostasis surplus of a wall of aneurism is excised, the ends of vessels wash out heparin and impose a proximal anastomosis of a prosthesis with an aorta. At first impose a back row of seams, stitches impose on an aorta from within a knaruzha an atraumatic needle with synthetic thread. If there is a discrepancy in calibers of an aorta and a prosthesis, the additional second row of seams is necessary.
Connection of the right ileal artery and a prosthesis make the end in the end or the end sideways. For a seam use 5 zero thread. It is necessary to put stitches at nek-rum a tension of a prosthesis. During the imposing of an anastomosis with an outside ileal artery the prosthesis should be carried out under an ureter. Upon termination of imposing of this anastomosis recover gradually a blood stream from an aorta in the right lower extremity, removing a clip from an aorta. Make continuous hemotransfusion according to arterial pressure at the patient. For this purpose can be required apprx. 20 — 30 min. The palpation of an aorta allows to define whether not too quickly there is a recovery of a blood-groove on an aorta.
After a hemostasis impose an anastomosis with the left ileal artery and recover a blood stream completely. After careful control of a hemostasis the site of a mesentery of a sigmoid gut together with a wall of aneurism is imposed on a prosthesis (fig. 15). The right leaf of a parietal peritoneum is hemmed to cover coats and plica duodenojejunalis so that the duodenum and proximal department of a jejunum keep within in normal situation. Basin and retroperitoneal space close two layers of a parietal peritoneum. It completely separates intestines from a prosthesis of an aorta on all lines of seams and protects from late complications in the form of aortoduodenal fistulas. As in the postoperative period the expressed dynamic intestinal impassability always develops, it is recommended to apply to mending of a wound of an abdominal wall a wire or strong naylonovy thread (in order to avoid discrepancy of seams at sharp swelling of intestines).
Aneurism of a ventral aorta in a stage of a gap
At operation special events are required. At the proceeding bleeding and need to press an aorta above renal arteries apply a hypothermia. At severe bleeding, when there is no time for adjustment of a hypothermia, use a local hypothermia of kidneys by an obkladyvaniye their sterile ice.
It is necessary to press as far as it is possible, large vessels still before the retroperitoneal hematoma is opened. After opening of an abdominal cavity choose a form of control of the proximal end of an aorta. If bleeding not too intensive, and aneurism has usual localization, then the aorta below renal arteries can be led round by a band in the usual way. If the hematoma extends up to a duodenum or goes to a mesentery of a cross colon, or it is very dense and strained, attempts to surround an aorta with a band in the field of an otkhozhdeniye of renal arteries can lead to a rupture of a hematoma and the death of the patient. In such cases of lig. coronarium hepatis can be crossed, the liver is taken away to the right and the gullet, as for transabdominal vagisection is naked. An aorta then it is possible to bare kzad from a gullet and to bring under it the strip entered into a tourniquet.
With such precautionary measures it is possible to enter a hematoma below renal arteries and in the stupid way to bypass an aorta. If the constitution of the patient complicates access to proximal department of an aorta or the hematoma extends to a diaphragm up, then it is necessary to make a thoracotomy and to press an aorta above a diaphragm. Further the aorta is allocated perhaps quicker with fingers on the site below renal arteries. The available retroperitoneal hematoma helps peeling of a wall And. and. from the lower vena cava. Immediately impose a clip one aorta higher than aneurism and begin hemotransfusion with the purpose to lift arterial pressure to physiological level and to bring the patient out of a condition of hemorrhagic shock. Further operation is carried out as it is described above.
Estimating indications to operation at aneurism of a ventral aorta, it is necessary to consider what without surgical treatment of the patient has much less chances of long life (fig. 16).
At operations for a gap And. and. most often there comes the acute renal failure owing to long hypotension with ischemia of kidneys.
during radical operations and in the next postoperative period the heaviest complications — bleeding, falling of arterial pressure after inclusion in a blood stream of a prosthesis, shock, a heart and renal failure, thrombosis of a prosthesis etc. The over-all mortality after a resection of uncomplicated aneurisms varies from 10 to 15%, and at complicated — to 60%.
In the remote period the most terrible complications are formation of false aneurisms in the area of an anastomosis and their penetration in a gleam of intestines (at interventions on a ventral aorta) and in a gleam of a gullet or bronchial tubes (at intervention on a chest aorta). In these cases repeated surgical intervention is shown.
Success achieved in surgical treatment of aneurisms allows to keep life of 70% of patients.
See also stratifying .
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