Combined membrane perforation through right atrium and femoral vein

Surgical treatment of Budd-Chiari syndrome by right atrial femoral vein combined with rupture. Budd-Chiari syndrome refers to hepatic venous hypertension, central venous and hepatic sinus dilatation, blood stasis or inferior vena cava blood stasis caused by obstruction of the hepatic vein outflow tract or inferior vena cava reflow. Clinical manifestations of portal hypertension such as hepatosplenomegaly Large, esophageal varices bleeding, ascites, hypersplenism, etc., can also be expressed as trunk and lower extremity varicose veins, lower extremity swelling, pigmentation and long-term ulcers. According to the vascular obstruction site, Budd-Chiari syndrome can be divided into inferior vena cava membranous and segmental obstruction, hepatic vein opening or distal extensive obstruction and hepatic vein inferior vena cava mixed obstruction. Due to the complicated classification and more surgical methods, there is no single method for treating Budd-Chiari syndrome of different pathological types. The treatment should be selected according to the pathological type. In recent years, the development of interventional radiotherapy has improved the treatment of Budd-Chiari syndrome. The interventional or interventional surgery has significantly improved the clinical efficacy of Budd-Chiari syndrome. Transatrial femoral vein combined with rupture of membrane is an important method for the treatment of membranous obstruction of the superior and inferior vena cava. With the development of interventional radiology, the inferior vena cava forming internal support has replaced the right atrial femoral vein combined with rupture of the membrane, significantly reducing Surgical complications improve clinical outcomes. However, patients with failed interventional therapy may be treated with a right atrial femoral vein combined with rupture of the membrane. Curing disease: Indication Trans right atrial femoral vein combined with rupture of membrane for: 1. Diaphragm type inferior vena cava obstruction, hepatic vein patency or only obstruction of the opening. 2. Localized inferior vena cava stenosis, hepatic vein patency or only obstruction of the opening. 3. Loss of balloon dilation. Contraindications 1. Fresh thrombus under the diaphragm exists. 2. Blockage of more than 3cm in length. 3. Hepatic vein localized obstruction. Preoperative preparation 1. In addition to routine examination, preoperative color Doppler and MRI angiography or electron beam CT angiography to understand the location and extent of vascular occlusion. 2, general anesthesia, take the right front chest incision, the right chest slightly higher, the right upper limb is fixed on the head frame; take the sternal median incision lying flat. Surgical procedure 1. From the midline of the iliac crest to the fourth intercostal space on the right side of the sternum, the skin and intercostal muscles are cut, the front edge of the fourth rib is cut, and the thoracic retractor is placed. Push open the right lung and reveal the right atrium. The pericardium is longitudinally cut in front of the sacral nerve, up to the superior vena cava, down to the bottom of the heart. Freely block the proximal inferior vena cava and wrap around. 2. Sew a traction line in the lower atrium of the right atrium, lift the traction line, use the heart-shaped pliers longitudinal clamp to clamp the right atrial side wall about 3cm long, and suture the atrial wall with a 4-0 non-invasive suture at the proximal atrial pliers. The thread is inserted into a thin rubber tube to control the right atrial incision to avoid bleeding after the incision. 3. Cut the right atrium, the right hand of the operator is quickly inserted into the right atrium while placing the happy ear pliers and tightening the purse string. Explore the diaphragm position and toughness along the inferior vena cava. 4. After the fingertip touches the diaphragm, it will evenly penetrate the diaphragm forward. Because the diaphragm is smooth and elastic, it is often necessary to apply it several times to break it through the force, and then rotate it in a clockwise direction. 5. When the diaphragm can not be worn, the balloon catheter or the inferior vena cava rupture device with the inner core can be inserted through the femoral vein, and the vasodilator is sent through the right atrial appendage, and the diaphragm is pierced under the combined action. expansion. 6. Fingers gradually withdraw from the inferior vena cava and right atrium, tighten the purse string, the heart ear clamps clamp the right atrium, cut off the purse suture and the traction line, and suture the right atrial incision continuously with 2-0 non-invasive suture. Ear pliers, carefully check for bleeding, and if necessary, add suture. The inferior vena cava was removed and the pericardium was partially sutured. 7. Thoroughly stop bleeding, place the chest drainage tube and suture the abdominal wall incision. complication Hemorrhagic shock The main reasons: 1 right atrial suture is not strict; 2 intrathoracic branch branch branch ligation is not complete; 3 inferior vena cava rupture; 4 coagulation dysfunction. Prevention: The right atrial suture should be tight after the rupture of the membrane, and the inferior vena cava and its branches should be carefully sutured and ligated to actively improve the general condition and coagulation function. 2. Pulmonary embolism Free thrombus detachment under the diaphragm after rupture of the membrane leads to acute pulmonary embolism after surgery. Prevention: After the membrane is broken, carefully explore the presence or absence of free thrombus under the diaphragm. Once it is found, it should be completely removed during the operation. Postoperative routine anticoagulation to prevent thrombosis.