Heart surgery for vascular transplantation. Diagnosis of renal artery stenosis after transplantation using MRI and CT images

• The incidence of complications is 1-23%.
• Stenosis renal artery is the most common complication after kidney transplantation
• Stenosis of the artery proximal to the anastomosis occurs if the donor or recipient suffers from atherosclerosis
• Stenosis in the area of ​​the anastomosis can form due to damage to the intima of the renal artery, which can occur when the donor kidney is removed or the arterial anastomosis technique is not followed.
• Stenosis distal to the anastomosis is observed when the renal artery is twisted, kinked, or compressed, as well as when the kidney is malpositioned after transplantation or in chronic organ rejection
• With renal artery stenosis of more than 50%, significant changes in hemodynamics occur.

Which method of diagnosing narrowing of the renal artery to choose: MRI, CT, ultrasound, angiography

Selection method

• Color Doppler ultrasound examination.

Why is Doppler ultrasound performed during a kidney transplant?

• Acceleration of blood flow in the stenotic area
• Turbulent blood flow in the area distal to the stenosis
• Significant image distortion due to vibration vascular wall
• The wave-like shape of the signal in the study of segmental arteries is due to a decrease in the filling of the pulse (pulsus parvus) and a decrease in the speed of passage of the pulse wave (pulsus tardus).

When is MRI of kidney vessels prescribed after transplantation?

• The presence of renal artery stenosis can be detected by 3D angiography.
• Attention: when using contrast agents containing gadolinium, the risk of developing nephrogenic systemic fibrosis increases.

What MSCT images will show in post-transplantation renal artery stenosis

• Iodine-containing contrast agents may be nephrotoxic
• In this regard, kidney dysfunction after transplantation is a contraindication to CT.

Is angiography of renal vessels performed?

• It is the method of choice for diagnosing renal artery stenosis, used to confirm post-transplantation renal artery stenosis and select treatment tactics for renal artery stenosis.

Clinical manifestations

Typical symptoms:

• Characteristic signs primary or secondary organ dysfunction after transplantation
• Worsening of the course arterial hypertension or the development of refractory hypertension.

Post-transplantation renal artery stenosis. Color Doppler ultrasound scan (a). The wave-like shape of the signal in the study of segmental arteries is due to a decrease in the filling of the pulse (pulsus parvus) and a decrease in the speed of passage of the pulse wave (pulsus tardus). The external contour of the transplanted organ is marked with arrowheads. When performing MRA with contrast, it is possible to visualize post-transplantation renal artery stenosis with localization distal to the anastomosis (arrow) (b) DSA before and after invasive therapy (percutaneous transluminal angioplasty with stenting) (c, d).

Principles of treatment of renal artery stenosis

• If indicated, percutaneous transluminal angioplasty is performed.
• Surgery is performed when the renal artery is twisted, there is no positive effect after percutaneous transluminal angioplasty, or it is impossible to access the artery using other methods.

Course and prognosis

• After performing transluminal percutaneous angioplasty, the prognosis is favorable in 80% of cases.

What would the attending physician want to know?

• Diagnosis of renal artery stenosis: location and degree of stenosis
• Level of perfusion of the transplanted organ.

What diseases have symptoms similar to renal artery stenosis

Post-transplant renal vein thrombosis

Lack of blood flow in renal vein and kidney parenchyma

Retrograde blood flow in the intrarenal branches of the renal artery observed in the diastole phase

Acute tubular necrosis, acute organ rejection

Increased value IR

When performing MRI, there is a risk of overdiagnosis of the degree of stenosis.

All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Modern medicine has stepped so far forward that today an organ transplant can no longer surprise anyone. This is the most effective and, sometimes, the only possible way to save a person’s life. Heart transplantation is one of the most complex procedures, but at the same time, it is extremely in demand. Thousands of patients wait for “their” donor organ for months and even years, many do not wait, and for some a transplanted heart gives a new life.

Attempts to transplant organs were made back in the middle of the last century, but the insufficient level of equipment, ignorance of some immunological aspects, and the lack of effective immunosuppressive therapy made the operation not always successful, the organs did not take root, and the recipients died.

The first heart transplant was performed half a century ago, in 1967, by Christian Barnard. It turned out to be successful and new stage in transplantology began in 1983 with the introduction of cyclosporine into practice. This drug made it possible to increase the survival rate of the organ and the survival rate of recipients. Transplantations began to be carried out all over the world, including in Russia.

The most important problem of modern transplantology is the lack of donor organs, often not because they are physically absent, but due to imperfect legislative mechanisms and insufficient awareness of the population about the role of organ transplantation.

It happens that relatives healthy person, who died, for example, from injuries, is categorically against giving consent to the collection of organs for transplantation to patients in need, even being informed of the possibility of saving several lives at once. In Europe and the USA, these issues are practically not discussed, people voluntarily give such consent during their lifetime, and in the countries of the post-Soviet space, specialists still have to overcome a serious obstacle in the form of ignorance and reluctance of people to participate in such programs.

Indications and obstacles to surgery

The main reason for transplanting a donor heart into a person is considered severe heart failure, starting from the third stage. Such patients are significantly limited in their life activities, and even walking short distances causes severe shortness of breath, weakness, and tachycardia. In the fourth stage, signs of a lack of cardiac function are present even at rest, which does not allow the patient to show any activity. Usually at these stages the survival prognosis is no more than a year, so the only way to help is to transplant a donor organ.

Among the diseases that lead to heart failure and can become testimony for heart transplantation, indicate:

When determining the indications, the patient's age is taken into account - he should be no more than 65 years old, although this issue is decided individually, and under certain conditions, transplantation is carried out for older people.

Others no less important factor consider the willingness and ability on the part of the recipient to follow the treatment plan after organ transplantation. In other words, if the patient obviously does not want to undergo a transplant or refuses to perform the necessary procedures, including postoperative period, then the transplantation itself becomes impractical, and the donor heart can be transplanted to another person in need.

In addition to the indications, a range of conditions incompatible with heart transplantation has been defined:

1. Age over 65 years (relative factor, taken into account individually);
2. Sustained increase in pressure in pulmonary artery over 4 units Wood;
3. System infectious process, sepsis;
4. Systemic diseases connective tissue, autoimmune processes (lupus, scleroderma, ankylosing spondylitis, active rheumatism);
5. Mental illness and social instability that prevent contact, observation and interaction with the patient at all stages of transplantation;
6. Malignant tumors;
7. Severe decompensated pathology of internal organs;
8. Smoking, alcohol abuse, drug addiction ( absolute contraindications);
9. Severe obesity can become a serious obstacle and even an absolute contraindication to heart transplantation;
10. The patient's reluctance to undergo surgery and follow the further treatment plan.

Patients suffering from chronic concomitant diseases, should be subjected to maximum examination and treatment, then the obstacles to transplantation may become relative. Such conditions include diabetes mellitus, correctable with insulin, gastric and duodenal ulcers, which can be put into remission through drug therapy, inactive viral hepatitis and some others.

Preparation for donor heart transplantation

Preparation for the planned transplant includes wide range diagnostic procedures, ranging from routine examination methods to high-tech interventions.

The recipient must:

• General clinical examinations of blood, urine, coagulation test; determination of blood group and Rh status;
• Tests for viral hepatitis (acute phase – contraindication), HIV (infection with the immunodeficiency virus makes surgery impossible);
• Virological examination (cytomegalovirus, herpes, Epstein-Barr) - even in an inactive form, viruses can cause an infectious process after transplantation due to immunosuppression, therefore their detection is a reason for preliminary treatment and prevention of such complications;
• Screening for cancer - mammography and cervical smear for women, PSA for men.

Besides laboratory tests, held instrumental examination: coronary angiography, which makes it possible to clarify the condition of the heart vessels, after which some patients can be referred for stenting or bypass surgery, Ultrasound of the heart, necessary to determine the functionality of the myocardium, ejection fraction. Shown to everyone without exception X-ray examination lungs, external respiration functions.

Among the invasive examinations used catheterization of the right half heart, when it is possible to determine the pressure in the vessels of the pulmonary circulation. If this indicator exceeds 4 units. Wood, the operation is impossible due to irreversible changes in the pulmonary blood flow, with a pressure in the range of 2-4 units. there is a high risk of complications, but transplantation can be performed.

The most important stage of examining a potential recipient is immunological typing according to the system HLA, based on the results of which a suitable donor organ will be selected. Immediately before the transplant, a cross-match test with the donor's lymphocytes is performed to determine the degree of suitability of both participants for organ transplantation.

During the entire waiting period for a suitable heart and the preparation period before the planned intervention, the recipient needs treatment for the existing cardiac pathology. For chronic heart failure, a standard regimen is prescribed, including beta blockers, calcium antagonists, diuretics, ACE inhibitors, cardiac glycosides, etc.

If the patient’s well-being worsens, the patient may be hospitalized at an organ and tissue transplantation center or a cardiac surgery hospital, where a special device can be installed that allows blood to flow through bypass routes. In some cases, the patient may be moved up the waiting list.

Who are the donors?

A heart transplant from a living healthy person is impossible, because taking this organ would be tantamount to murder, even if the potential donor himself wants to give it to someone. The source of hearts for transplantation is usually people who died from injuries, road accidents, or victims of brain death. An obstacle to a transplant may be the distance that the donor heart will need to travel on the way to the recipient - the organ remains viable for no more than 6 hours, and the shorter this interval, the more likely the success of the transplantation.

An ideal donor heart would be an organ that is not affected by coronary disease, whose function is not impaired, and whose owner is under 65 years of age. At the same time, hearts with some changes can be used for transplantation - initial manifestations of atrioventricular valve insufficiency, borderline hypertrophy of the myocardium of the left half of the heart. If the recipient’s condition is critical and requires transplantation as soon as possible, then a less than “ideal” heart can be used.

The transplanted organ must be suitable in size for the recipient, because it will have to contract in a rather limited space. The main criterion for matching donor and recipient is immunological compatibility, which determines the likelihood of successful graft engraftment.

Before collecting a donor heart, an experienced doctor will examine it again after opening the chest cavity; if all is well, the organ will be placed in a cold cardioplegic solution and transported in a special thermally insulated container. It is advisable that the transportation period does not exceed 2-3 hours, a maximum of six, but it is already possible ischemic changes in the myocardium.

Heart transplant technique

A heart transplant operation is possible only in conditions of established artificial circulation; it involves more than one team of surgeons, who replace each other at different stages. The transplantation is lengthy, taking up to 10 hours, during which the patient is closely monitored by anesthesiologists.

Before the operation, the patient’s blood is tested again, coagulation, blood pressure levels, blood glucose levels, etc. are monitored, because there will be long-term anesthesia under artificial circulation. The surgical field is processed in the usual way, the doctor makes a longitudinal incision in the sternum, opens the chest and gains access to the heart, where further manipulations take place.

At the first stage of the intervention, the recipient’s heart ventricles are removed, while great vessels and the atria are preserved. Then, a donor heart is sutured to the remaining organ fragments.

There are heterotopic and orthotopic transplantation. The first method is to preserve the recipient's own organ, and the donor heart is located to the right below it, anastomoses are performed between the vessels and chambers of the organ. The operation is technically complex and time-consuming, requires subsequent anticoagulant therapy, two hearts cause compression of the lungs, but this method is preferable for patients with severe pulmonary hypertension.

Orthotopic transplantation is carried out both by directly suturing the atria of the donor heart to the atria of the recipient after excision of the ventricles, and bicaval by, when both vena cava are sutured separately, which makes it possible to reduce the load on the right ventricle. At the same time, plasty of the tricuspid valve can be performed in order to prevent its insufficiency later.

After the operation, immunosuppressive therapy with cytostatics and hormones is continued to prevent donor organ rejection. When the patient’s condition stabilizes, he awakens and switches off artificial ventilation lungs, the dose of cardiotonic drugs is reduced.

In order to assess the condition of the transplanted organ, myocardial biopsies are performed - once every 1-2 weeks in the first month after surgery, then less and less often. Hemodynamics are constantly monitored and general state sick. Healing postoperative wound occurs over the course of one to one and a half months.

heart transplant

The main complications after a heart transplant can be bleeding, requiring re-operation and its stop, and graft rejection. Rejection of a transplanted organ - serious problem all transplantology. The organ may not take root immediately, or rejection may begin after two to three or more months.

In order to prevent donor heart rejection, glucocorticosteroids and cytostatics are prescribed. For prevention infectious complications antibiotic therapy is indicated.

During the first year after surgery, patient survival reaches 85% or even more due to improvements in surgical techniques and immunosuppression methods. In the longer term, it decreases due to the development of the rejection process, infectious complications, and changes in the transplanted organ itself. Today, up to 50% of all patients who have undergone a heart transplant live longer than 10 years.

A transplanted heart can work for 5-7 years without any changes, but the processes of aging and degeneration develop in it much faster than in a healthy own organ. This circumstance is associated with a gradual deterioration in health and an increase in the failure of the transplanted heart. For the same reason, the life expectancy of people with a transplanted healthy organ is still lower than the general population.

Patients and their relatives often have a question: is a repeat transplant possible if the graft wears out? Yes, technically this can be done, but the prognosis and life expectancy will be even shorter, and the likelihood of engraftment of the second organ will be significantly lower, so in reality, repeated transplants are extremely rare.

The cost of the intervention is high, because it itself is extremely complex, requires the presence of qualified personnel and a technically equipped operating room. The search for a donor organ, its collection and transportation also require material costs. The organ itself is given to the donor free of charge, but other costs may have to be paid.

On average, an operation on a paid basis will cost 90-100 thousand dollars, abroad - naturally, more expensive - reaches 300-500 thousand. Free treatment is provided according to the system health insurance, when a patient in need is put on a waiting list and, in turn, if a suitable organ is available, he will undergo surgery.

Given the acute shortage of donor organs, free transplantations are performed quite rarely, and many patients never receive them. In this situation, treatment in Belarus may become attractive, where transplantation has reached the European level, and the number of paid operations is about fifty per year.

The search for a donor in Belarus is greatly simplified due to the fact that consent to heart removal is not required in the event of brain death. In this regard, the waiting period is reduced to 1-2 months, the cost of treatment is about 70 thousand dollars. To resolve the issue of the possibility of such treatment, it is enough to send copies of documents and examination results, after which specialists can provide indicative information remotely.

In Russia, heart transplantation is performed in only three large hospitals– Federal Scientific Center for Transplantology and Artificial Organs named after. V. I. Shumakov (Moscow), Novosibirsk Research Institute of Circulatory Pathology named after. E. N. Meshalkin and North-Western Federal Medical Research Center named after. V. A. Almazova, St. Petersburg.

Of greatest interest in relation to the function and fate of the alloprosthesis is the process of formation, maturation and subsequent involution of the internal lining (neointima) of the prosthesis. At different times after transplantation and in different areas, it has a different structure. The internal fibrin film is gradually replaced by a connective tissue lining. Its surface is gradually covered with endothelium, growing from the side of anastomoses with vessels, as well as from islands of endothelialization...

It has been established that the larger the size and number of pores and the smaller the thickness of the prosthesis, the more fully and in a shorter time the tissue ingrowth, formation and endothelialization of the neointima occurs (L. P. Tolstova, 1971; Wesolowski, 1962). At the same time, the thickness of the inner membrane and the entire newly formed vascular wall is less, which favors the nutrition of the intima, its endothelialization and connection with the entire wall, reduces...

The main factors that disrupt the hemodynamic conditions of the functioning of prostheses, which favor thrombosis, are turbulence of blood flow, as well as a decrease in the linear and volumetric velocities of blood flow in the prosthesis (A. N. Filatov et al., 1965; Szilagyi et al., 1964). The degree of turbulization depends on the difference in the diameters of the prosthesis and the bypassed artery: the greater the disproportion of diameters, the greater the turbulization of the blood flow. Reduced blood flow through the prosthesis...

During long periods of implantation in the body, the prosthesis is exposed to factors that affect the physicochemical properties of polymer materials - periodic stretching by a pulse wave, mechanical compression when bending the joints, aggressive influence biological fluids. As a result of changes in the physicochemical properties of the prosthesis (“fatigue” of polymer materials), their strength, elasticity, and resilience decrease. So, 5 years after implantation, the loss of strength is 80%...

The following main points can be highlighted in the technique of alloplastic reconstruction of arteries. First, the necessary intervention is performed on the affected vessel and it is prepared for anastomosis. Select a prosthesis suitable in diameter and length (try it on the wound in a stretched form). Its diameter should be 3-5 mm larger than the diameter of the corresponding vessel. Prepare the edges of the prosthesis by cutting it with sharp scissors. At…

To palliative vascular operations include surgical interventions on blood vessels that eliminate some pathological disorders, complications that make it possible to somewhat improve blood circulation and the patient’s condition. Thus, the overwhelming majority of ligature operations are palliative, and some of them, for example, ligation of a narrow formed arteriovenous fistula with two ligatures, are reconstructive. Palliative operations used to be the main type surgical interventions for diseases and damage to blood vessels...

WITH late XIX Until now, a variety of materials have been proposed for replacing blood vessels - biological (vessels and other tissues) and alloplastic (artificial vascular prostheses). Of the many methods of reconstruction of arteries by transplantation, studied experimentally and tested in the clinic, currently mainly two are used: plastic surgery of arteries with a vein and alloplasty with synthetic vascular prostheses...

Nutrition of the relatively thin vein wall in initial period after a free transplant, it occurs due to the blood passing in its lumen. Vascular connections are restored 2-3 weeks after transplantation outer shell veins with surrounding tissues. Degeneration and sclerosis of its wall are usually not expressed to a significant extent and the elastic elements of the tissue are preserved, which determine the mechanical strength and stability of the wall...

The technique of autovenoplasty of arteries is as follows. The large saphenous vein of the thigh is isolated and it is ensured that its diameter is consistent and that its lumen is not obliterated. If an anastomosis with femoral artery, then the vein and artery are isolated from one longitudinal access. In this case, it is advisable to begin the operation by isolating the vein, since tissue displacement after exposure of the artery is often...

Currently, in the surgery of obliterating arterial diseases, the bypass technique is used with anastomoses of both the end-to-side and end-to-end type. End-to-end anastomoses are used more often for plastic surgery of traumatic arterial defects, after removal of aneurysms, or for artery resections of limited extent. When performing an end-to-side anastomosis,...

The problem of organ shortage for transplantation is urgent for all humanity as a whole. About 18 people die every day due to the lack of organ and soft tissue donors without waiting their turn. Organ transplantation in modern world for the most part, it is produced from deceased people who, during their lifetime, signed the appropriate documents indicating their consent to donation after death.

What is transplantation

Organ transplantation involves removing organs or soft tissue from a donor and transferring them to a recipient. The main direction of transplantology is organ transplantation - that is, those organs without which existence is impossible. These organs include the heart, kidneys, and lungs. While other organs, such as the pancreas, can be replaced by replacement therapy. Today, organ transplantation offers great hope for prolonging human life. Transplantation is already being successfully practiced. These are the kidneys, liver, thyroid gland, cornea, spleen, lungs, blood vessels, skin, cartilage and bones to create a framework so that new tissues can form in the future. For the first time, a kidney transplant operation to eliminate acute renal failure The patient was performed in 1954, the donor was an identical twin. Organ transplantation in Russia was first performed by Academician B. V. Petrovsky in 1965.

What types of transplantation are there?

All over the world there is great amount terminally ill people in need of transplantation of internal organs and soft tissues, since traditional ways Treatments for the liver, kidneys, lungs, and heart provide only temporary relief, but do not fundamentally change the patient’s condition. There are four types of organ transplantation. The first of them - allotransplantation - occurs when the donor and recipient belong to the same species, and the second type includes xenotransplantation - both subjects belong to different types. In the case when tissue or organ transplantation is performed in or animals raised as a result of consanguineous crossing, the operation is called isotransplantation. In the first two cases, the recipient may experience tissue rejection, which is caused by the body's immune defense against foreign cells. And in related individuals, tissues usually take root better. The fourth type includes autotransplantation - transplantation of tissues and organs within one organism.

Indications

As practice shows, the success of the operations is largely due to timely diagnosis and precise definition the presence of contraindications, as well as how timely the organ transplant was performed. Transplantation must be predicted taking into account the patient's condition both before and after surgery. The main indication for surgery is the presence of incurable defects, diseases and pathologies that cannot be treated with therapeutic and surgical methods, and life-threatening patient. When performing transplantation in children, the most important aspect is determining the optimal moment for the operation. As experts from such an institution as the Institute of Transplantology testify, the operation should not be postponed unreasonably. long term, because developmental delay young body may become irreversible. Transplantation is indicated in case of a positive life prognosis after surgery, depending on the form of the pathology.

Organ and tissue transplantation

In transplantology, autotransplantation is most widespread, as it eliminates tissue incompatibility and rejection. Most often, operations are performed on fatty and muscle tissue, cartilage, bone fragments, nerves, pericardium. Vein and vascular transplantation is widespread. This became possible thanks to the development of modern microsurgery and equipment for these purposes. A great achievement in transplantology is the transplantation of fingers from the foot to the hand. Autotransplantation also includes transfusion of one's own blood in case of large blood losses during surgical interventions. During allotransplantation, the most commonly transplanted Bone marrow, vessels, This group includes blood transfusions from relatives. It is much rare to carry out operations on this because so far this operation faces great difficulties, however, in animals, transplantation of individual segments is successfully practiced. A pancreas transplant can stop the development of this serious illness like diabetes. In recent years, 7-8 out of 10 operations performed have been successful. In this case, not the entire organ is transplanted, but only part of it - the islet cells that produce insulin.

Law on organ transplantation in the Russian Federation

On the territory of our country, the transplantology industry is regulated by the Law of the Russian Federation of December 22, 1992 “On Transplantation of Human Organs and (or) Tissues.” In Russia, kidney transplantation is most often performed, and less often heart and liver transplantation. The law on organ transplantation considers this aspect as a way to preserve the life and health of a citizen. At the same time, the legislation considers the preservation of the life of the donor to be a priority in relation to the health of the recipient. According to the Federal Law on organ transplantation, objects can be heart, lung, kidney, liver and others internal organs and fabrics. Organ removal can be carried out both from a living person and from a deceased person. Organ transplantation is carried out only with the written consent of the recipient. Only legally capable persons who have undergone a medical examination can be donors. Organ transplantation in Russia is carried out free of charge, since the sale of organs is prohibited by law.

Donors for transplantation

According to the Institute of Transplantology, every person can become a donor for organ transplantation. For persons under eighteen years of age, parental consent is required for the operation. When you sign a consent to donate organs after death, a diagnosis and medical examination is carried out to determine which organs can be transplanted. HIV carriers are excluded from the list of donors for organ and tissue transplantation. diabetes mellitus, cancer, kidney disease, heart disease and other serious pathologies. Related transplantation is carried out, as a rule, for paired organs - kidneys, lungs, as well as unpaired organs - liver, intestines, pancreas.

Contraindications for transplantation

Organ transplantation has a number of contraindications due to the presence of diseases that can be aggravated as a result of the operation and pose a threat to the patient’s life, including leading to fatal outcome. All contraindications are divided into two groups: absolute and relative. The absolute ones include:

• infectious diseases in other organs on a par with those that are planned to be replaced, including the presence of tuberculosis and AIDS;
• disruption of the functioning of vital organs, damage to the central nervous system;
• cancerous tumors;
• the presence of malformations and birth defects that are incompatible with life.

However, during the period of preparation for surgery, thanks to treatment and elimination of symptoms, many absolute contraindications become relative.

Kidney transplant

Kidney transplantation is of particular importance in medicine. Since this is a paired organ, when it is removed, the donor does not experience disruptions in the functioning of the body that threaten his life. Due to the peculiarities of the blood supply, the transplanted kidney takes root well in the recipients. The first experiments on kidney transplantation were carried out in animals in 1902 by researcher E. Ullman. During transplantation, the recipient, even in the absence of supportive procedures to prevent rejection, foreign organ lived a little over six months. Initially, the kidney was transplanted onto the thigh, but later, with the development of surgery, operations began to transplant it into the pelvic area, a technique that is still practiced today. The first kidney transplant was performed in 1954 between identical twins. Then in 1959, an experiment was carried out on kidney transplantation of fraternal twins, which used a technique to counteract graft rejection, and it proved its effectiveness in practice. New agents have been identified that can block the body's natural mechanisms, including the discovery of azathioprine, which suppresses immune protection body. Since then, immunosuppressants have been widely used in transplantology.

Organ preservation

Any vital organ that is intended for transplantation is subject to irreversible changes without blood supply and oxygen, after which it is considered unsuitable for transplantation. For all organs, this period is calculated differently - for the heart, time is measured in a matter of minutes, for the kidney - several hours. Therefore, the main task of transplantology is to preserve organs and maintain their functionality until transplantation into another organism. To solve this problem, canning is used, which consists of supplying the organ with oxygen and cooling. The kidney can be preserved in this way for several days. Preservation of an organ allows you to increase the time for its examination and selection of recipients.

Each of the organs, after receiving it, must be preserved; for this, it is placed in a container with sterile ice, after which preservation is carried out with a special solution at a temperature of plus 40 degrees Celsius. Most often, a solution called Custodiol is used for these purposes. Perfusion is considered complete if a clean preservative solution without blood admixtures emerges from the mouths of the graft veins. After this, the organ is placed in a preservative solution, where it is left until the operation.

Graft rejection

When a transplant is transplanted into the recipient's body, it becomes the object of the body's immunological response. As a result of a defensive reaction immune system The recipient undergoes a number of processes at the cellular level that lead to rejection of the transplanted organ. These processes are explained by the production of donor-specific antibodies, as well as antigens of the recipient’s immune system. There are two types of rejection - humoral and hyperacute. At acute forms Both mechanisms of rejection develop.

Rehabilitation and immunosuppressive treatment

To prevent this side effect Immunosuppressive treatment is prescribed depending on the type of surgery performed, blood type, degree of donor-recipient compatibility, and the patient’s condition. The least rejection is observed with related transplantation of organs and tissues, since in this case, as a rule, 3-4 antigens out of 6 coincide. Therefore, a lower dose of immunosuppressive drugs is required. The best survival rate is demonstrated by liver transplantation. Practice shows that the organ demonstrates more than ten years of survival after surgery in 70% of patients. With prolonged interaction between the recipient and the transplant, microchimerism occurs, which allows the dose of immunosuppressants to be gradually reduced over time until they are completely abandoned.

Tuesday is the day of the operation. The team is preparing for a long morning of work. During the operation, the chest is opened and the heart is prepared for vessel transplantation.

Disease history

Mr. Thomas, a 59-year-old tanker driver, is married with two adult children. He had shingles with right side neck, and then there was an uncomfortable feeling of constriction in the throat, accompanied by sweating and nausea. He first felt these symptoms while walking up the steps of his truck. They continued, and Thomas decided to seek advice from a therapist.

High arterial pressure, Thomas's obesity and long history of smoking were sufficient reasons for an ECG to be performed. Its results showed the presence coronary disease hearts. Thomas was referred to a cardiac expert (a physician who specializes in heart problems - not a surgeon). Despite the drug treatment, the pain continued.

Tests confirmed the presence of the disease, including an angiogram (a test using dye injected into an artery to identify narrowing) that revealed a narrowing in the left main coronary artery, affecting both the left and right vessels. Because drug treatment was unsuccessful and angioplasty (stretching the narrowed vessel using a catheter) was not an option, Mr. Thomas was referred for surgery.

Monday

Mr. Thomas is hospitalized. His anamnesis, examination and test data were analyzed. Two units of blood for transfusion are examined for compatibility. The patient is explained the essence of the operation and warned about the risks associated with it. Obtain written consent for CABG.

Tuesday

Early in the morning, Mr. Thomas is prepped for surgery.

7:05 Premedication and anesthesia

8:15 Mr. Thomas was premedicated 70 minutes ago and a ventilation tube is already in place. Airways. After applying anesthesia and paralyzing agents, his breathing is supported by a ventilator. Before Mr. Thomas is transferred to the operating room, the anesthesiologist monitors venous and arterial blood flow.

8:16 The operating room is ready for Mr. Thomas. On the left is a table with instruments, on the right is a ready-to-use heart-lung apparatus.

8:25 Patient in the operating room. Skin his chest and the legs are treated antiseptic solution to reduce the risk of infection.

8:40 Chest opening

The skin has already been treated, the patient is dressed in sterile clothing. One of the surgeons makes an incision in the leg to remove the vein, and the second one cuts the skin on the chest. After making a preliminary cut with a regular scalpel, he uses an electric one, which cuts the vessels, stopping the bleeding.

8:48 The surgeon divides sternum electric saw with pneumatic drive.

8:55 Artery and vein removal

View of the internal mammary artery in the mirror in the center of the surgical lamp. This artery is very elastic. The top end will remain in place, it will be cut off at the bottom and then connected to the coronary artery.

An angled retractor is placed along the left edge of the sternum to elevate it and expose the mammary artery running along the sternum. inside breasts

At the same time, one of the main veins in the leg - the great saphenous vein - is prepared for transplantation. It was almost completely removed from the left thigh.

9:05 Connection to the heart-lung machine

The heart-lung machine is not yet connected to the patient. One of the five rotating pumps circulates the blood, and the rest are used as side pumps to transport the separated blood to prevent blood loss during surgery. The patient must be given heparin, a drug that thins the blood and prevents the formation of clots as it passes through plastic tubes.

Tubes for the heart-lung machine. On the left - with bright red blood - is the arterial return line, along which blood is flowing back into the patient's aorta. On the right are two tubes that drain blood from the inferior and superior vena cava under the influence of gravity. The incision in the sternum is secured with a spacer.

Part of the heart-lung machine is a membrane oxygenating device that maintains blood circulation in the patient's body. IN this moment the device is filled with blood, carbon dioxide is removed from it. The blood is re-oxygenated and returned to the patient's body.

An arterial return tube is inserted into the aorta (the main artery of the body), and two venous drains are inserted into the vena cava ( main vein body).

9:25 Cardiac arrest

A clamp is placed on the main artery, the aorta, isolating the heart from artificial blood circulation. A cooled fluid is injected into the isolated aorta to stop the heart. The surgeon puts on special glasses for microsurgery with loupes that provide 2.5 times magnification. The blood vessels he will transplant have a diameter of 2-3 mm, and the sutures are the diameter of a human hair.

A thorough check of the heart is performed to confirm the findings from the angiogram. It is specified which coronary arteries needs to be shunted. It was decided to make two shunts.

After stopping the blood flow in the left anterior descending artery, a 1 cm incision is made using a surgical loop at the bypass site.

10:00 First bypass

Close-up of a heart. The left internal mammary artery - in the upper left corner - is sutured to the left anterior descending artery so that blood flow to the heart is restored. The arteries are hidden by epicardial fat.

The end of the left internal mammary artery is sutured laterally to the left anterior descending artery. This creates the first bypass shunt.

Position of the first shunt performed. The lower end of the left internal mammary artery, a 3 mm blood vessel, is completely sutured to the left anterior descending artery.

10:22 Second bypass

The second bypass shunt is sewn with its upper end to the aorta, and its lower end to the right posterior descending artery. The cross clamp is removed and blood flow through the heart is restored.

The upper end of the venous shunt connects to the aorta. Part of the aorta is isolated with an arcuate clamp, and a hole is made into which the vein is sutured.

End of both bypass processes. The second shunt, shown on the left side of the diagram, is formed from saphenous vein shins.

11:18 Closing the chest

Blood circulation is restored, the heart contracts after the electric shock with a transition from ventricular fibrillation into sinus mode. Two drains are installed in the front and back of the heart. The blood thinning effect of heparin was eliminated by the drug protamine. The surgeon stitches the separated halves of the sternum. He will close the skin with an internal absorbable suture.

The nurse places tape on the stitch and on the drainage tubes leading from the patient's chest. The patient will soon be admitted to the ward intensive care where it will be observed.

The human body. Outside and inside. №1 2008