Transplantation(late lat. transplantatio, from transplanto- transplantation), tissue and organ transplantation.
Transplantation in animals and humans is the engraftment of organs or sections of individual tissues to replace defects, stimulate regeneration, during cosmetic operations, as well as for the purposes of experiment and tissue therapy. The organism from which the material for transplantation is taken is called a donor, the organism into which the transplanted material is implanted is called a recipient, or host.
Types of transplantation
Autotransplantation - transplantation of parts within one individual.
Homotransplantation - transplantation from one individual to another individual of the same species.
Heterotransplantation - a transplant in which the donor and recipient are related different types one kind.
Xenotransplantation - a transplant in which the donor and recipient belong to different genera, families and even orders.
All types of transplantation, as opposed to autotransplantation, are called allotransplantation .
Transplanted tissues and organs
In clinical transplantology, autotransplantation of organs and tissues is most widespread, because With this type of transplantation there is no tissue incompatibility. Transplantations of skin, adipose tissue, fascia (muscle connective tissue), cartilage, pericardium, bone fragments, nerves.
Vein transplantation, especially the great saphenous vein of the thigh, is widely used in vascular reconstructive surgery. Sometimes resected arteries are used for this purpose - the internal iliac artery, the deep femoral artery.
With implementation in clinical practice microsurgical technology, the importance of autotransplantation has increased even more. Transplantations on vascular (sometimes nerve) connections of skin, musculocutaneous flaps, muscle-bone fragments, and individual muscles have become widespread. Transplantations of toes from the foot to the hand, transplantation of the greater omentum (fold of peritoneum) to the lower leg, and intestinal segments for esophagoplasty have become important.
An example of organ autotransplantation is a kidney transplant, which is performed for extensive stenosis (narrowing) of the ureter or for the purpose of extracorporeal reconstruction of the vessels of the renal hilum.
A special type of autotransplantation is the transfusion of the patient’s own blood during bleeding or deliberate exfusion (withdrawal) of blood from the patient’s blood vessel 2-3 days before surgery for the purpose of its infusion (administration) to him during surgical intervention.
Tissue allotransplantation is used most often for transplantation of the cornea, bones, bone marrow, and much less often for transplantation of pancreatic b-cells for the treatment of diabetes mellitus, hepatocytes (for acute liver failure). Brain tissue transplants are rarely used (for processes accompanying Parkinson's disease). Mass transfusion of allogeneic blood (blood of brothers, sisters or parents) and its components is a mass transfusion.
Transplantation in Russia and in the world
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 effects of 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…
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 of surgical interventions for diseases and vascular injuries….
From the end of the 19th century to the present day, 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...
In the initial period after a free transplant, the relatively thin vein wall is nourished by the blood passing through 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. Allocate a large saphenous vein thighs and make sure that its diameter is consistent and that there is no obliteration of its lumen. If an anastomosis with the femoral artery is intended, 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,...
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 a 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 of a healthy person who died, for example, from injuries, are categorically against giving consent to the collection of organs for transplantation to needy patients, 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.
Another equally important factor is the desire 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 undergo necessary procedures, including in the 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:
- Age over 65 years (relative factor, taken into account individually);
- Sustained increase in pressure in pulmonary artery over 4 units Wood;
- System infectious process, sepsis;
- Systemic diseases connective tissue, autoimmune processes (lupus, scleroderma, ankylosing spondylitis, active rheumatism);
- Mental illness and social instability that prevent contact, observation and interaction with the patient at all stages of transplantation;
- Malignant tumors;
- Severe decompensated pathology of internal organs;
- Smoking, alcohol abuse, drug addiction (absolute contraindications);
- Severe obesity can become a serious obstacle and even absolute contraindication to heart transplantation;
- The patient's reluctance to undergo surgery and follow the further treatment plan.
Patients suffering from chronic concomitant diseases should be subjected to maximum evaluation and treatment, then the obstacles to transplantation may become relative. Such conditions include diabetes, correctable with insulin, stomach and duodenal ulcers, which through drug therapy Inactive viral hepatitis and some others can be put into remission.
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.
In addition to laboratory tests, instrumental examinations are carried out: 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 of the lungs, respiratory function.
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 in as soon as possible, then a not quite “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 the great vessels and 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. The hemodynamics and general condition of the patient are constantly monitored. 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 through the health insurance system, when a patient who needs it 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.
Slide 2
Atraumatic instruments
To perform operations on blood vessels, it is necessary to use special atraumatic instruments that ensure delicate handling. vascular wall. Much credit for their development belongs to American vascular surgeons at the Mayo Clinic, as well as Michael DeBeki. Vascular instruments include vascular forceps with atraumatic cutting, thin and well-knit vascular scissors, sharp vascular scalpels, soft vascular clamps with long ratchet clamps. The application of general surgical clamps to the main arteries leads to inevitable thrombosis of the latter. To temporarily clamp large vessels, you can use tourniquets (loops made of thin fragments of infusion systems, onto which pieces of thicker drainage tubes are placed). Various probes and catheters are widely used (for example, the Fogarty catheter for embolectomy).
Slide 3
Slide 4
Access
In modern vascular surgery, basic surgical approaches have been developed to all large vessels, mainly to the areas of forks. When performing access, it is necessary to observe the principles of atraumatic opening of the vessel's own fascial sheath: The vascular sheath is opened, as a rule, bluntly, using a dissector. Sometimes a solution of novocaine is injected into the vagina to avoid reflex spasm. The separation of the artery and vein is performed extremely carefully. Movements with the instrument are made “from the vein”, i.e. try not to point the tip of the dissector towards the wall of the vein to avoid its rupture. The vessel must be separated from the surrounding tissue on all sides for the length necessary for convenient application of clamps. They try to remove sympathetic nerve fibers from the surface of the vessel. Thus, we perform periarterial sympathectomy and eliminate reflex vasospasm in the periphery.
Slide 5
PROJECTIONS OF THE MAIN VASCULAR-NEW BUNCHES OF THE LIMB
OPERATIVE ACCESS TO VESSELS: DIRECT – carried out strictly along the projection line (to deep-lying formations) CIRCULAR – carried out outside the projection line (to superficially lying formations)
Slide 6
REQUIREMENTS for the vascular suture:
Creation of tightness along the anastomosis line; There should be no narrowing of the lumen along the suture line; The sutured ends of the vessel along the suture line should touch the inner membrane - the intima; The suture material should not be in the lumen of the vessel; There should be no obstacles to the blood flow in the area where the suture is applied; The edges of the vessel should be trimmed sparingly; The vessel should not dry out; The distance between stitches is 1 mm.
Slide 7
VASCULAR SURE
CLASSIFICATION: By method of application: hand stitch; mechanical suture - performed using a vascular stapling device. In relation to the circumference: Lateral (up to 1/3); Circular (over 2/3); a) Wrapping (Carrel, Morozova seam); b) Everting (suture of Sapozhnikov, Braitsev, Polyantsev); c) Intussusception (Soloviev’s suture). a b c http://4anosia.ru/
Slide 8
Currently, a polypropylene (non-absorbable) atraumatic thread is used to apply a vascular suture. In adults, this is a continuous wrapping seam according to the “outside in - inside out” pattern. In young children, a U-shaped interrupted suture is used. Historical meaning They have everting sutures, A. Carrel’s suture, as well as a mechanical (hardware) vascular suture.
Slide 9
Seam F. Briand and M. Jabouley
This is the so-called U-shaped, intermittent (knotted) everting suture. Such a suture will not impede the growth of the anastomotic zone if it is used in young body. The principle of adaptation of the intima with everting stitches, proposed by the authors, has found its application and further development in a large number of modifications (E.I. Sapozhnikov, 1946; F.V. Balluzek, 1955; I.A. Medvedev, 1955; E.N. Meshalkin, 1956; Y.N. Krivchikov, 1959 and 1966; V. Dorrance, 1906; A. Blalock, 1945; I. Littman, 1954).
Slide 10
Seam I. Murphy
J. Murphy in 1897 proposed a circular invagination method of vascular suture. At first, this modification attracted attention, since the problem of sealing the suture was solved quite simply, but the basic principle of vascular anastomosis - contact of intima with intima - was violated by simple invagination of one segment into another. Therefore, the suture used by the author and other researchers, as a rule, led to thrombosis, and Murphy’s original idea was forgotten for a long time.
Slide 11
Seam A. Carrel
The Carrel seam is an edge wrapping seam, continuous, between three knot holders, which are applied through all layers at an equal distance from each other. The stitch frequency depends on the thickness of the vessel wall and varies from 0.5 to 1 mm. This technique has become widespread and is used most often, being the basis for the development of numerous modifications of vascular connections.
Slide 12
Dorrance suture a - stage I; b - stage II
The Dorrance seam (V. Dorrance, 1906) is marginal, continuous, two-story
Slide 13
Shov L.I. Morozova
Shov A.I. Morozovaya (a simplified version of the Carell seam) is also a wrapping, continuous, but involves the use of only two holders. The role of the third holder is performed by the thread of the continuous seam itself.
Slide 14
Application of marginal sutures in case of discrepancy in the caliber of vessels a - method N.A. Dobrovolskaya; b - method Yu.N. Krivchikova; c - method of Seidenberg, Hurvit and Carton
ON THE. Dobrovolskaya in 1912 proposed an original suture for connecting vessels with different diameters (Fig. a). In order to ensure good adaptation of such vessels, the circumference of the smaller one is increased by applying two notches located 180° from each other. For the same purpose, Zaidenberg and his colleagues (1958) intersected a vessel with a smaller diameter in the zone of its division (Fig. c), and Yu.N. Krivchikov (1966) and P.N. Kovalenko and his colleagues (1973) cut the end of a smaller vessel at an angle (Fig. b).
Slide 15
Shov N.A. Bogoraz (suturing a vessel defect by fixing a patch)
Shov N.A. Bogoraz (1915) is a plastic suturing large defect in the vessel wall by fixing the patch with a continuous wraparound marginal suture after preliminary application of stay sutures at the corners of the defect.
Slide 16
Strengthening the area of vascular anastomosis a - method V.L. Henkin; b - SP method. Shilovtseva
For better sealing of the vascular anastomosis line, N.I. Bereznegovsky (1924) used a piece of isolated fascia. V.L. Henkin proposed autovein and allograft for this purpose (Fig. a), and SP. Shilovtsev (1950) - muscle (Fig. b).
Slide 17
Shov A.A. Polyantseva (twisting, continuous between three U-shaped holders)
Slide 18
Shov E.I. Sapozhnikov (continuous welt-like between two knot holders)
Shov E.I. Sapozhnikova (1946) - continuous, welt-shaped, between two nodal holders. A thread with two straight needles is used, which are injected towards each other at the base of the cuffs.
Slide 19
The seam back wall if it is impossible to rotate the vessel (I) and invagination suture according to G.M. Solovyov (II): I: a - method of L. Blelock, b - method of E.N. Meshalkin, in the form of this seam after tightening the thread; II: a-c - stages of seam formation
Slide 20
Method Yu.N. Krivchikova a - application of U-shaped sutures; b - formation of the cuff; i - application of a continuous U-shaped suture; d - strengthening the cuff
Yu.N. Krivchikov (1959) developed an original intussusception suture (Fig. a-d) with a single cuff (everting, covered with a cuff created from the vessel itself). This modification, according to the author, ensures good adaptation of the intima and minimal protrusion of threads into the lumen of the vessel, creates a reliable seal and also allows the formation of a reinforcing cuff from any segment of the vessel.
Slide 21
Ring I.I. Palavandishvili (stretching handles using springs)
I.I. To simplify the technique of applying a hand suture according to Carrel, Palavandishvili (1959) created a metal ring with a diameter of 12 cm with three springs to which the holders are attached. Such a device gives the lumen of the vessel triangular shape and frees the assistant's hands.
Slide 22
Shov G.P. Vlasov (prevention of narrowing of the anastomotic zone)
The peculiarity of the proposed circular seam, in contrast to the continuous one with overlaps, is that both ends of the threads “walk” one after another and are connected to each other. The stitch formed resembles a machine stitch, only the longitudinal thread is located on one side. Advantages this method consist, firstly, in the fact that there is no corrugation of the walls of the stitched vessels between the stitches; secondly, the longitudinal arrangement of twisted threads along the roller between the stitches promotes close contact of the walls of the vessels and reduces the possibility of bleeding.
Slide 23
Seam A.M. Demetsky (prevention of narrowing of the anastomotic zone)
A.M. Demetsky (1959) proposed a suture that eliminates narrowing of the anastomotic zone. The author cut off the ends of the sutured vessels at an angle of 45°, while the length of the suture and the flow hole in the anastomosis zone increased by 2 times.
Slide 24
Method N.G. Starodubtseva (prevention of narrowing and turbulence in the anastomosis area)
N.G. Starodubtsev and co-workers (1979) developed and studied in detail a new type of anastomosis, in which its narrowing is eliminated and the conditions for the occurrence of turbulent blood flow are practically eliminated. This type of connection is called a “Russian castle” anastomosis.
Slide 25
Shov J.N. Gadzhieva and B.Kh. Abasov (inverting double-sided continuous mattress) a - initial stage; b - final stage
A peculiar modification of the vessel suture was developed by J.N. Gadzhiev and B.Kh. Abasov (1984). In order to increase the tightness and prevent bleeding from the anastomosis, prevent narrowing of the anastomotic zone and thrombosis of the reconstructed arteries, the authors proposed an everting bilateral continuous mattress suture.
Slide 26
I. Littman seam (intermittent mattress between three U-shaped supports)
Littman suture (1954) - an interrupted mattress suture between three U-shaped supports that are applied at equal distances from each other.
Slide 27
restoration of blood vessels using the Donetsk gauge
Slide 28
Reconstructive operations are performed to restore the main blood flow in case of vascular obstruction
Disobliterating operations - aimed at restoring the patency of an occluded segment of a vessel: Thrombus - or embolectomy: a) Direct (through an incision in the vessel) b) Indirect (with a Fogarty catheter from another vessel) Thrombendarterectomy - removal of a blood clot along with thickened intima. Plastic surgeries are aimed at replacing the affected vessel segment with an auto-, allo-, xenograft or vascular prosthesis. Bypass surgery - with the help of vascular prostheses or an autograft, an additional path for blood flow is created, bypassing the occluded segment of the vessel. http://4anosia.ru/
Slide 29
A variant of endarterectomy with sewing in a patch is angioplasty. Plastic surgery of the deep femoral artery (profundoplasty) according to Martin. The superficial femoral artery is occluded. An autovenous patch was sewn into the mouth of the deep femoral artery. According to Yu.V. Belov
Slide 30
BYPASS A bypass to bypass the obstruction to blood flow. At the same time, the possibility of residual blood flow is preserved. Femoral-popliteal bypass surgery Bifurcation aorto-femoral bypass surgery (Lerisch operation), BABS According to Yu.V. Belov, Burakovsky-Bockeria
Slide 31
PROSTHETICS Application of a bypass path to bypass the obstruction to blood flow with complete exclusion of the affected area from the blood flow. Bifurcation aorto-iliac prosthesis for an aneurysm of the infrarenal aorta with transition to both aortas. According to Yu.V. Belov
Slide 32
Stents
In modern intravascular surgery, many techniques have become possible thanks to the use of intravascular stents. Stents - weeding tubes - holding devices located in the lumen of the vessel. They were first developed by Charles Dotter in the late 60s of the 20th century. Many modifications of stents have been proposed. Basically, they can be divided into three groups. Balloon expandable. These are the stents used most often. The stent is placed on an inflating catheter balloon. Inflating the balloon causes stretching of the wire structure of the stent, the latter expands, cuts into the wall of the vessel and is fixed. Self-expanding stents are guided to the area of interest inside the introducer catheter, and then pushed into the lumen with a mandrel. Expansion of the spring stent leads to its fixation in the vessel wall. Thermal expandable stents.
Slide 33
Stents are used either independently as devices for permanent dilatation of a vessel, or together with intravascular prostheses to retain them. When treating false arterial aneurysms, a Dacron endoprosthesis with two stents at the ends is endovascularly applied to them and fixed by expanding the stents. The aneurysm cavity is switched off from the bloodstream. Surgeries on the aortic arch may require turning off the natural blood flow and require complex equipment. An antiproliferative drug-coated stent is an intravascular prosthesis made of a coated cobalt-chromium alloy that releases a drug substance that prevents re-narrowing of the vessel. The medicinal layer subsequently dissolves.
Slide 34
MODERN TECHNOLOGIES IN VASCULAR SURGERY Intravascular dilation and stenting Balloon catheter with Palmaz stent Coronary angiogram before and after the procedure
Slide 35
ANEURYSMSTrue False (traumatic) TYPES: arterial venous arteriovenous
Three groups of operations: surgical interventions, the purpose of which is to cause a cessation or slowdown of blood flow in the aneurysmal sac and thereby contribute to the formation of a blood clot and obliteration of the cavity or a decrease in the volume of the aneurysmal sac. This is achieved by ligating the leading end of the artery proximally from the aneurysmal sac (Anel and Gunther methods); operations in which the aneurysmal sac is completely excluded from the circulation (Antillus method) or its removal like a tumor (Filagrius method); operations aimed at restoring completely or partially blood circulation by suturing the arterial fistula through the aneurysmal sac - endoaneurysmorrhaphy (methods of Kikutsi - Matas, Radushkevich - Petrovsky) Currently, operations are mainly performed to exclude the aneurysm from the bloodstream or remove it and replace it with a vascular prosthesis. http://4anosia.ru/
Slide 36
OPERATIONS FOR VARICOSE VEINS OF THE LOWER EXTREMITIES
There are 4 groups of operations: removal of veins, ligation of the main and communicating veins, sclerosis of veins, combined. ACCORDING TO MADELUN - removal through an incision along the entire length of the BSVB ACCORDING TO BABCOCK - removal of the BSVB using a probe through 2 small incisions ACCORDING TO NARATU - ligation and removal of dilated veins on the lower leg through separate incisions ACCORDING TO TROYANOV-TRENDELENBURG - high ligation of the BSVB at the point of confluence with the femoral ACCORDING TO COCKET - suprafascial ligation of the communicants ACCORDING TO LINTON - subfascial ligation of the communicants ACCORDING TO SHEDE, ACCORDING TO CLAP - percutaneous ligation of veins (for scattered veins) The Troyanov-Trendelenburg-Babcock-Narat operation is more often performed. http://4anosia.ru/
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Definition and synonyms of cardiovascular surgery
Cardiovascular surgery is a medical surgical specialty within which surgical interventions are performed varying degrees complications on the heart and large blood vessels, such as the aorta, pulmonary trunk, etc. In principle, cardiovascular surgery was previously a branch of general surgery, but as surgical techniques became more complex, the requirements for the doctor’s qualifications increased accordingly. To master the techniques of operations on the heart and blood vessels, surgeons needed to study a large amount of information, and to maintain their professional skills at the proper level, perform only these surgical operations. In addition, for operations on the heart and blood vessels, it was necessary to develop special auxiliary manipulations, such as a heart-lung machine, anesthesia technique, and others, which provide an optimal result with minimal risk of complications. In general, we can say that cardiovascular surgery has become a separate medical specialty just like all others (for example, gastroenterology, pulmonology, etc.) due to the increasing volume of knowledge and the need for narrow specialization.Cardiovascular surgery in American and European medical schools is classified as a specialty cardiothoracic surgery , which is somewhat different from the Russian version. Cardiothoracic surgery includes all possible surgical procedures in the chest cavity, that is, cardiovascular surgery in the Russian structure of specialties, and additionally all operations on the lungs, esophagus, etc. That is, a cardiothoracic surgeon has a broader specialty compared to a Russian cardiovascular surgeon.
In addition, in the countries of the former USSR, cardiovascular surgery is often called cardiac surgery , since most of the operations performed by doctors of this specialty are one or another intervention on the heart and its vessels.
What operations are performed as part of cardiovascular surgery?
Cardiovascular surgery includes: various operations on the heart or large vessels if present serious illnesses the latter, which cannot be eliminated conservatively. Most often, cardiovascular surgeons perform operations to treat coronary heart disease, heart failure and arrhythmias, as well as to eliminate congenital or acquired defects and tumors of the heart, aorta or pulmonary trunk. The reasons that led to the formation of severe defects, tumors or coronary disease heart, are not important for cardiac surgery, since during surgery normal physiological state organ. This allows you to improve the functioning of the organ, improve the patient’s quality of life and significantly prolong his life. In addition, cardiovascular surgery includes heart or large vessel transplantation in its range of activities.Currently, in the centers or departments of cardiovascular surgery, specialists of the relevant profile perform the following surgical interventions:
- Vascular bypass surgery (aorto-femoral bifurcation, iliofemoral, femoral-popliteal, aorto-coronary);
- Elimination of aortic aneurysm (prosthetics, bypass surgery, etc.);
- Elimination of aneurysm of the left ventricle of the heart;
- Stenting of large vessels (for example, carotid, femoral, coronary arteries, etc.);
- Balloon angioplasty (restoration of blood vessel patency);
- Introduction and installation of a pacemaker;
- Elimination of congenital and acquired heart defects;
- Replacement of a heart valve with a special prosthesis;
- Aortic valve replacement;
- Heart valve transplant;
- Heart transplant;
- Treatment of infective endocarditis;
- Pulmonary artery catheterization;
- Pericardiocentesis.
Almost all cardiovascular operations are aimed at eliminating any mature or congenital structural disorder of the heart or blood vessels, which is fatal. This means that the goal of cardiovascular surgery is to restore the blood supply to the heart itself, as well as its ability to pump out blood, ensuring adequate blood supply to all other organs and systems.
Congenital defects are usually detected in childhood and, accordingly, are operated on by pediatric cardiovascular surgeons. In the vast majority of cases, adults have various acquired diseases that lead to deformation of the structure of the heart and blood vessels, which interferes with normal life. As a rule, if such disorders are not corrected in time during the necessary cardiovascular surgery, then the person dies within a short period of time, since the heart and blood vessels are not able to provide the volume of functions necessary to maintain life.
Thus, we can conclude that cardiovascular surgery is the last possible method of treating diseases of the heart and blood vessels associated with disorders of their structure and functioning.
For what diseases is cardiovascular surgery used?
Cardiovascular surgery is usually used when conservative treatment turns out to be ineffective and the disease progresses steadily. Doctors are also forced to treat diseases of the heart and blood vessels surgically if a person applies for medical care on late stages, When conservative therapy will be ineffective and useless.Currently, cardiovascular surgery using the above operations treats the following diseases:
- Cardiac ischemia;
- Heart failure functional class II – III;
- Pulmonary embolism (PE);
- Mitral, tricuspid or aortic valve defect caused by rheumatism, consequences of the inflammatory process (pericarditis, endocarditis, etc.), trauma or other reasons;
- Stenosis (sharp narrowing of the lumen) of the aortic valve caused by any reason;
- Infective endocarditis;
- Aneurysm of the aorta or left ventricle of the heart;
- Some types of arrhythmia ( ventricular tachycardia, bradyarrhythmia and atrial fibrillation), which can be eliminated with a pacemaker;
- The presence of pericardial effusion, which creates tamponade and prevents the heart from pumping out the required volume of blood normally. Such tamponade can form during myocardial infarction, tuberculosis, connective tissue diseases, viral infections, malignant neoplasms and uremia;
- Pulmonary hypertension;
- Severe left ventricular failure;
- Myocardial infarction with severe complications, such as severe hypotension, sinus tachycardia, ventricular septal rupture, acute mitral regurgitation or cardiac tamponade;
- Acute myocardial infarction;
- Coronary artery stenosis caused by atherosclerosis or other reasons;
- Angina;
- The presence of an episode of resuscitation for sudden cardiac death syndrome;
- People involved in ensuring the safety and health of others (for example, pilots, bus drivers, etc.) who have a cardiac abnormality as determined by stress tests, even if it does not manifest clinical symptoms.
Cardiovascular surgery can be performed several times during a person's life. Typically, subsequent surgical procedures are performed when complications develop, relapses, insufficient effectiveness of the previous operation, deterioration of the person’s condition, or the addition of another pathology.
Brief description of the most common cardiovascular operations
Let us consider which operations from the arsenal of cardiovascular surgery are used in various cases to treat certain diseases of the heart and large vessels.Coronary artery bypass grafting (CABG)
This operation is the sewing of an additional blood vessel through which the blood supply to the heart will occur instead of blocked and damaged coronary arteries. To understand the essence of the operation, you need to imagine a hose through which water flows. If the hose is blocked in any area, water will stop flowing beyond that area. However, if we insert a small piece of hose into the slits in the pipe so that one of its holes is above the blockage and the second below, we will get a shunt through which water can flow further again.The same thing is done during coronary artery bypass grafting. That is, those vessels through which blood normally flows to the heart muscle become too narrow due to atherosclerotic plaques and cannot provide the required volume of blood. Because of this, the heart muscle (myocardium) experiences oxygen starvation– suffers from ischemia. And since delete atherosclerotic plaques and in some cases it is impossible to expand the lumen of blood vessels, they resort to applying a bypass shunt. One end of the shunt is inserted into the aorta, and the other into a section of the coronary arteries located beyond the site of severe narrowing. Typically, multiple shunts are placed during surgery to ensure blood supply to all areas of the heart muscle (see Figure 1).
Picture 1– Scheme of application of direct shunts.
A vein isolated from the tissues of the forearm or lower leg is usually used as a bypass.
Coronary artery bypass surgery is performed when the lumen of the coronary vessels is narrowed by at least 70% of normal. Until a narrowing of the coronary vessels occurs by the specified amount, coronary artery bypass surgery is not performed, even if the person has experienced more than one heart attack and suffers from angina, shortness of breath and heart failure. This is due to the fact that the volume of the operation is very large, and with a smaller percentage of narrowing of the coronary arteries, it is quite possible to resort to other, less invasive techniques restoration of blood supply to the heart muscle, such as angioplasty and stenting.
Angioplasty
Angioplasty is the restoration of the patency of the heart and other vessels by expanding their lumen from the inside with special devices. This entire cardiovascular operation is called percutaneous transluminal coronary angioplasty (PTCA). To perform PTCA, special devices are required in the form of deflated balloon-shaped balls, which are inserted into the narrowed cardiac vessel through carotid artery. That is, the balloon is first inserted into the carotid artery, then gradually moves through the blood vessels up to the coronary vessels and is inserted into the required sharply narrowed area. In this section, the balloon is inflated so that its volume expands the lumen of the vessel. Thanks to this manipulation, the coronary vessel receives normal lumen and the ability to provide the necessary volume of blood for the myocardium.Angioplasty is performed when there is a sharp narrowing of one or more coronary vessels, when oxygen deficiency develops in any limited area of the myocardium supplied with blood from this blocked artery. In such a situation, angioplasty allows you to restore blood supply to the myocardium without resorting to a major surgical operation of coronary artery bypass grafting.
However, in the long term, angioplasty is not a reliable treatment for coronary artery stenosis, since quite often the procedure must be repeated due to recurrence of narrowing of the vessel. Coronary artery bypass grafting has certain advantages over angioplasty, since it allows normalizing the blood supply to the myocardium for long term without the risk of its disruption due to recurrence of coronary artery stenosis. But cardiovascular surgeons consider the primary production of angioplasty justified, as a more gentle and less invasive method of treatment, which allows achieving a pronounced therapeutic effect. If the blood supply to the myocardium can be restored with the simpler manipulation of angioplasty, then there is no need to resort to the much more complex operation of coronary artery bypass grafting, which, in fact, is the last treatment option.
Besides, in last years managed to significantly increase the effectiveness of angioplasty and reduce the risk of recurrent stenosis through the use of special devices - stents. The angioplasty procedure involving the placement of stents is called stenting surgery.
Stenting
Stenting is more effective procedure angioplasty with stent placement. All manipulations during stenting are almost the same as during angioplasty, that is, a special balloon is inserted into the narrowed vessel, expanding its lumen. Then, to hold the vessel in this position and, accordingly, prevent its re-stenosis, it is fixed with stents. The stent has an appearance similar to a regular spring (see Figure 2), which is inserted into the lumen of the vessel after it is dilated. For manipulation, various modifications of stents are used, which are selected by the doctor depending on the size and condition of the narrowed coronary vessel. After stenting surgery, it is necessary to take antiplatelet agents - drugs that prevent active thrombus formation. The optimal antiplatelet agents currently are Clopidogrel and Aspirin.The effectiveness of stenting is comparable to coronary artery bypass grafting, but it is much simpler and less invasive. Therefore, people who do not have 70% or more narrowed heart arteries are recommended to undergo stenting rather than coronary artery bypass grafting.
Figure 2– Various modifications of stents
Introduction and installation of a pacemaker
The introduction and installation of a pacemaker is carried out to normalize the heart rhythm and prevent deadly arrhythmias, in the development of which a person, as a rule, does not have time to save. Currently there are various models pacemakers, which are selected individually depending on the type of arrhythmia. Typically, the pacemaker is inserted through the carotid artery, just like a stent or angioplasty balloon. Then the device is adjusted to the person and left for life, periodically changing the batteries in it.Removal of aortic aneurysm or left ventricular wall
An aneurysm is a thinning and simultaneous protrusion of the wall of an organ. Accordingly, an aortic or ventricular aneurysm is a thinning of the wall of a given blood vessel or heart and its protrusion into the chest cavity. Any aneurysm is very dangerous, since the thinned wall of the vessel or ventricle of the heart may not withstand the blood pressure and rupture. In such a situation, a person dies almost instantly.If a person is diagnosed with an aneurysm of the aorta or ventricle of the heart, then they resort to surgical treatment, which consists of excision of a thinned section of the organ, suturing the free ends of its wall and draping it over a special mesh made of durable material. The mesh supports the wall of the aorta or ventricle of the heart, preventing it from thinning and bulging again, forming a new aneurysm.
Elimination of heart and vascular defects
Elimination of heart and vascular defects is complex surgical intervention, during which doctors completely correct existing anatomically incorrect organ structures. For example, in the absence of a septum between the ventricles or atria, an abnormal structure of blood vessels and valves, and other similar conditions, doctors can, during an operation, transform the structure of the organ into a normal one, removing unnecessary parts and sewing on the necessary ones. In most cases, heart and vascular defects are successfully eliminated by experienced specialists in the field of cardiovascular surgery.Surgeries to eliminate heart and vascular defects must be performed as soon as possible after their detection. If these are detected in newborns, then they can be operated on literally from the first day of birth. In some cases, the baby’s life depends on how quickly the operation is performed and the congenital heart or vascular defect is eliminated.
Prosthetics and transplantation of heart valves, aorta or pulmonary valve
The valves of the heart, aorta or pulmonary trunk are susceptible to various diseases with the formation of defects, which are a change in their normal anatomical shape with functional insufficiency. With defects, the valves of the heart and large vessels collapse loosely and do not open completely, as a result of which blood is poorly pushed into the systemic and pulmonary circulation and is thrown back, which causes various clinical symptoms. To eliminate this pathology, cardiovascular surgeons simply remove the defective valve during the operation and insert a prosthesis in its place. Modern prosthetic heart valves and blood vessels are of excellent quality and can completely normalize hemodynamics. Valves can be entirely artificial, created from synthetic materials, or natural, made from bovine or pork tissue. Biological valves take root well, but wear out quickly, so they have to be replaced frequently (once every 3 to 5 years) with new ones. And artificial valves last until a person’s death, but after their installation it is necessary to constantly take antiplatelet drugs (Clopidogrel or Aspirin).
Replacement of heart valves is carried out using a catheter, which is inserted into the vessels and advanced along them to the required area. Then, through the same catheter, the doctor removes the worn valve and installs a new one in its place. The operation is relatively simple and non-invasive, so the patient does not actually need to go to the hospital for several weeks to have the heart valves or blood vessels replaced.
Pulmonary artery catheterization involves the insertion of a special hollow catheter into the pulmonary trunk. This operation is performed under different acute diseases heart or blood vessels (for example, shock, cardiac tamponade, myocardial infarction, pulmonary hypertension, etc.), when it is necessary to normalize a person’s condition or distinguish one pathology from another. The operation is performed under local anesthesia and under X-ray control. Currently, pulmonary artery catheterization is carried out primarily for diagnostic purposes to distinguish between diseases that manifest similar clinical symptoms.
Treatment of infective endocarditis
Currently, the term “endocarditis” refers to any infectious and inflammatory process that affects the inner lining of the ventricles or atria of the heart, valves and endothelium of surrounding blood vessels. Most often in the practice of a cardiovascular surgeon, valvular endocarditis occurs that has developed in tissue areas directly adjacent to the implanted prosthesis.If endocarditis develops, conservative treatment with antibiotics or surgery. Surgery with subsequent support with antibiotics and their introduction directly into the tissues affected by inflammation is performed only in cases of circulatory failure of stages NYHA III–IV or NYHA II with hemodynamic defects.
Surgical treatment of endocarditis can be performed more than once during a person’s life.
Pericardiocentesis
Pericardiocentesis is a puncture of the outer lining of the heart in order to suction the existing effusion and further determine the cause of its occurrence. Pericardiocentesis is a diagnostic procedure that allows you to find out the cause of fluid accumulation between the muscle layer and the outer heart sac. The most common causes of effusion between the pericardium and myocardium are the following conditions:- Tuberculosis;
- Viral infection;
- Connective tissue diseases;
- Increased level of urea in the blood;
- Malignant tumors;
- Myocardial infarction;
- Complications after heart surgery.
Heart transplant
A heart transplant is a technically complex operation, which is performed only in cases where nothing else can be done to help the sick person. Typically, a heart transplant can extend a person's life by at least 5 years.Features of cardiovascular surgery (heart-lung machine, chest incision, catheter access)
For heart operations, a heart-lung machine is often used in surgical practice. Since in other operations this device is not used, then it can be confidently attributed to the peculiarities of cardiovascular surgery. During the entire operation, this device pumps blood through the vessels instead of the heart, which is emptied to obtain optimal visibility of the affected tissues and, accordingly, improve the quality of the surgeon’s work.
A heart-lung machine is a pump with various devices through which the blood of the human body passes and is saturated with the necessary amount of oxygen. To start it, the surgeon makes an incision in the aorta and inserts a large cannula connected to a heart-lung machine. The second cannula is inserted into the atrium and blood also flows through it to the device. In this way, the blood circulation is closed in a circle due to the apparatus, and not the heart.
Venous blood from the atrium flows out due to gravity and enters the heart-lung machine, where the pump pumps it into the oxygenator and saturates it with oxygen. From the oxygenator, blood is pumped through a filter into the arterial cannula and, under pressure, flows directly into the aorta. This is how continuous blood supply to organs and tissues is ensured against the background of an immobilized heart on which the operation is performed.
For operations on the heart, aorta or pulmonary trunk, it is necessary to gain access to them, that is, to get inside the chest. To do this, you need to somehow penetrate the ribs that form the rigid frame of the chest. In cardiovascular surgery, two main types of incisions are used to open the chest and gain access to the heart and blood vessels:
1.
Sawing the sternum along its entire length and opening the chest completely by stretching the ribs in different directions.
2.
An incision is made between the 5th and 6th ribs and stretched to the sides.
In each case, the doctor decides which incision will be made to gain access to the heart and blood vessels based on the person’s condition and his own preferences.
Besides, characteristic feature Cardiovascular surgery is catheter access for certain operations and diagnostic procedures. So, catheter access is the insertion of a hollow catheter tube into any large vein, for example, the femoral, iliac, jugular (under the armpit) or subclavian. Then this catheter is advanced through the blood vessels to the heart, aorta or pulmonary trunk and, having reached the required area, is fixed. Then, under X-ray or ultrasound control, the necessary instruments or prostheses are delivered through this catheter using a thin and flexible wire-like string, which is used to perform the operation. This catheter access allows the operation to be performed in a day hospital without resorting to general anesthesia and opening the chest cavity. Accordingly, the deadline full recovery after surgery performed through catheter access, much less compared to opening the chest cavity. Catheter access has become widespread for angioplasty, stenting, heart and aortic valve replacement, and pacemaker installation. Thanks to this access, the above operations are performed quickly and allow you to normalize your health.
