[Hybrid operations in treatment of patients with multi-level lesions of lower limb arteries]. / Gibridnye operatsii v lechenii patsientov s mnogourovnevym porazheniem arterii nizhnikh konechnostei.

The article is a review of literature dedicated to simultaneous open and endovascular (hybrid) operations in treatment of patients with chronic ischaemia of lower limbs. Despite good results of endovascular interventions, in many situations involvement of arteries below the inguinal fold and multilevel lesions are arguments in favour of performing an open operation. On the other hand, open multilevel interventions are accompanied by an increased risk of complications and mortality. Hybrid interventions appear to be a safe and efficient alternative combining advantages of two methods of treatment and making it possible to achieve an optimal outcome with a minimal surgical wound. Also discussed herein are the problems of terminology, indications for, techniques and results of treatment, providing a historical background, followed by analysing problem spots of using this technique and trends of development.

[Amputation as an anticipated consequence of peripheral artery disease and ways to improve the prognosis of limb salvage]. / Amputatsiia kak ozhidaemoe posledstvie zabolevanii perifericheskikh arterii i puti uluchsheniia prognoza sokhraneniia konechnostei.

Peripheral artery disease is a common and acute social burden worldwide. The main method of treatment of PAD consists in open surgical or endovascular revascularization. However, despite steady growth of the number and quality of interventions, the incidence of lower-limb amputation still remains at a high level. Lower-limb amputation is a severe psychological blow for the patient and leads to significant deterioration of his or her quality of life, as well as has an extremely negative prognosis concerning the frequency of subsequent complications and survival. Consequences of amputations include not only severe disability but also an unfavourable prognosis of life, thus determining the necessity of adequate prevention of such events. Reconstructive and endovascular operations, as well as amputations are associated with a significant increase of the probability of the development of major adverse cardiovascular events, the frequency of repeat hospitalizations and, finally, the cost of treatment. Prescribing pathogenetically substantiated antithrombotic therapy is considered to be one of the methods to improve the results of surgical treatment and prognosis for the patient. Presented in the article is a literature review making it possible to assess the risks and consequences of amputations in patients with PAD, as well as to determine therapy capable of improving the prognosis.

[Key aspects of drug therapy in vascular surgery]. / Kliuchevye aspekty medikamentoznoi terapii v sosudistoi khirurgii.

Peripheral arterial disease (PAD) is one of the most common manifestations of systemic atherosclerosis. PAD affects millions of people worldwide, thus greatly contributing to the structure of mortality and disability of the population of developed countries. Along with surgical revascularization, pharmacotherapy is becoming increasingly important in improving the prognosis in such patients. Modern clinical guidelines define optimal therapy for patients with PAD as simultaneous prescription of several classes of drugs (hypolipidemic, antithrombotic, antihypertensive and, probably, vasodilators), thus making it necessary for the surgeon to take into consideration possible drug interactions. This literature review presents the evolution of evidence-based approaches to drug therapy and an algorithm of choosing drugs, depending on initial risk for ischaemic events in patients with peripheral arterial disease.

[Ways of decreasing incidence of complications in patients after endured reconstructive and endovascular operations on lower limb arteries]. / Puti snizheniia chastoty oslozhnenii u bol'nykh, perenesshikh rekonstruktivnye i éndovaskuliarnye operatsii na arteriiakh nizhnikh konechnostei.

Peripheral artery disease represented predominantly by atherosclerosis obliterans is a common social burden all over the world. The main method of treatment for peripheral artery disease (PAD) is considered to be open surgical or endovascular revascularization. Unfortunately, despite a steadily growing number of operations and implementation of new types of interventions, including endovascular ones, the prognosis in patients with peripheral artery diseases still remains unfavourable. Moreover, patients having endured revascularization are susceptible to especially high risk of subsequent ischaemic complications from the side of both the cardiovascular system as a whole (strokes, infarctions, cardiovascular death) and the limb in the form of progressing ischaemia, development of critical and/or acute ischaemia. All the above mentioned determines the necessity of carrying out intensive accompanying medicamentous therapy. At the same time, the contemporary literature contains contradictory results of using different drugs in order to decrease the risk for progression of lower limb ischaemia, as well as the incidence of adverse cardiovascular events in the form of strokes, infarctions, and cardiovascular death. Disputable remains the question of whether monotherapy with acetylsalicylic acid still remains the only well evidence-based method of treatment in randomized multiple-centre studies. There are various opinions on the place of dual anticoagulant and antiplatelet therapy in treatment of PAD. The findings of the multi-centre randomized COMPASS trial published in 2018 significantly altered the approaches to medicamentous therapy of this patient cohort. The purpose of our study was to carry out a systematic review of literature, making it possible to assess the risks and prognosis in patients presenting with peripheral artery disease after a vascular intervention, as well as to determine therapy capable of improving the outcomes of surgical treatment.

[Bleedings after reconstructive operations on the aorta, its branches, and peripheral arteries (on materials of the Department of Vascular Surgery A.N. Bakulev ICVS of the Academy of Medical Sciences of the USSR, 1961-1983)]. / Krovotecheniia posle rekonstruktivnykh operatsii na aorte, ee vetviakh i perifericheskikh arteriiakh (po materialam otdeleniia khirurgii sosudov ISSKh im. A.N. Bakuleva AMN SSSR, 1961-1983 gg.).

The authors retrospectively analysed episodes of bleeding after reconstructive operations on the aorta, its branches, and peripheral arteries. The sources of information were the archival medical records of the Department of Vascular Surgery of formerly the Institute of Cardiovascular Surgery named after A.N. Bakulev under the USSR Academy of Medical Sciences (now known as the National Medical Research Centre of Cardiovascular Surgery named after A.N. Bakulev) over the period from 1961 to 1983. A total of 3,787 operations on the aorta and arteries had been performed over that time period. Bleedings were observed in 170 cases (4.5% of all interventions), with the mortality rate amounting to 25.3%. Of these, 72 bleedings (42.3%) were primary, to have developed from anastomoses or sutures of the artery, with 38 (22.3%) being secondary (arrosive) and 10 (5.9%) related to hypocoagulation. In the remaining 50 (29.4%) episodes, the blood had leaked from tissues (en masse). Of these, no source of bleeding had been identified in 8 (4.7%) cases. The subjects of investigation were the terms of bleeding onset, localization, causes, dependence from suture material. The authors suggested a tentative classification of postoperative bleeding. It was determined that 50.6% of these events had developed within the first 24 postoperative hours. Primary bleedings were found to have more often occurred from sutures of the thoracic aorta (58.3%) and arrosive ones from the femoral artery (60%). The causes of primary bleedings were determined to be as follows: cuts of the vascular wall by suture material (66.7%) or needle entry holes (15%), defects between sutures of an anastomosis (14%), defects of an autovein in the area of an anastomosis (2.8%), separation of fibers of the graft in the area of an anastomosis (1.4%). Also analysed are the methods of final arrest of haemorrhage. The authors believe that this historical experience may be used to improve qualification of vascular surgeons.

[First experience with monitoring somatosensory and motor evoked potential during operations on the thoracic and thoracoabdominal portions of the aorta].

Specialists in Russia have recently gained vast experience in operations on the thoracic and thoracoabdominal portion of the aorta; however, studying evoked potentials for preventing lesions of the spinal marrow have not been studied in any clinic. The authors report herein their first experience in Russia in studying the function of the marrow during operations on the aorta followed by detailed description of the technique of registering evoked potentials. From June 2010 to January 2011, specialists of the Arterial Pathology Department of the A. N. Bakulev Scientific Centre for Cardiovascular Surgery under the Russian Academy of Medical Sciences carried out a neurophysiological study in a total of 19 patients during operations for thoracic and thoracoabdominal aortic aneurysms. The somatosensory and motor evoked potentials were studied using an 8-channel neuroenhancer Keypoint (Dantec, Denmark). The hospital mortality rate in the examined group amounted to 5.2% (1/19). Spinal stroke developed in 2 patients, i.e. in 10.5% (2/19). The alterations in the somatosensory and motor evoked potentials were subdivided into groups according to the morphological classification of Crawford-Cunningham. A further two patients were found to have during operation type III changes in the evoked potentials, with both having developed postoperative spinal stroke. Thus, the method of intraoperative monitoring of evoked potentials has high sensitivity and specificity and can be included into the protocol of operations on the thoracic and abdominothoracic portion of the aorta. During monitoring of evoked potentials it is necessary to maintain a permanent level of anaesthesia and myorelaxation with obligatory participation of the neurophysiologist in the operation.

[Remote results of open interventions in treatment of abdominal aortic aneurysms].

Analysed herein are the results of treating a total of 471 patients operated on at the Department of Surgical Treatment for Arterial Pathology of the Research Centre of Cardiovascular Surgery named after A. N. Bakulev under the Russian Academy of Medical Sciences for an aneurysm of the infrarenal portion of the abdominal aorta. Complicated forms of AAA were observed in 71 (15.1%) patients. Of these, 13 patients were admitted presenting with a clinical picture of aortic rupture, 56 patients with aortic wall tear (according to ultrasound and/or MSCH findings), and two patients had break of the inferior vena cava. The most frequently encountered accompanying diseases were as follows: CAD noted in 367 (78.2%) patients. Valvular heart defects were revealed in 68 (14.4%) patients. Atherosclerotic alterations of the ascending aorta were diagnosed in 97 (20.6%) patients, and an ascending aortic aneurysm in 14 (2.8%) patients. Operations on the heart were performed in 45 (19.1%) patients. Mitral valve plasty was carried out in 7 patients, and 11 patients had a history of prior interventions on the aortic root and ascending aorta (Bentall-De Bono operation in 3 patients, Carbol operation in 3 patients). 32 patients underwent reconstructive operations on coronary arteries. Transmyocardial laser revascularization of the myocardium was carried out in 4 patients. Endovascular interventions were performed in 32 (6.8%) patients (stenting or transluminal balloon angioplasty of coronary arteries). All patients underwent AAA resection with prosthetic repair. The mentioned operations were combined with the following simultaneous interventions: aortocoronary bypass grafting performed in 31 cases, carotid endarterectomy in 27 cases, and plasty of renal arteries was carried out in 48 patients. Complications in the immediate postoperative period were observed in 79 (16.8%) patients. Hospital mortality amounted to 11 (2.3%) patients. The cumulative survival rate after 1, 5 and 10 years after surgery amounted to 93%, 81% and 44%, respectively, in a complicated course amounting to 91%, 79% and 16%, respectively. The obtained findings of the study demonstrated that the results of the AAA resection should be regarded as fairly good. The main factors influencing the quality of life and surgical outcomes in abdominal aortic aneurysms are as follows: CAD, arterial hypertension, and chronic cerebrovascular diseases. In patients without accompanying diseases, the criteria of quality of life after surgery approximate to those in a healthy population.

[Extra-anatomical bypass grafting from the ascending to the descending aorta combined with removal of the thoracic-aorta stent graft and a para-aortic abscess following endoscopic repair of the descending portion of the thoracic aorta].

The outcomes of reconstructive repair operations for aneurysms of the descending portion of the thoracic aorta typically appear to be relatively satisfactory. However, a certain cohort of patients presenting with the pathology concerned require repeated secondary interventions due to the development of false aneurysms in the area of the anastomosis and infection of the synthetic vascular stent graft, with the number of such patients steadily increasing with each year. The authors describe herein a clinical case report regarding successful treatment of a patient diagnosed with an infected pseudoaneurysm of the descending portion of the thoracic aorta after an endovascular repair operation. This case report demonstrated a present-day approach to appropriate treatment of patients presenting with the pathology involved.

[On the classification of dissecting aortic aneurysms].

Aortic dissections are most commonly categorized into types A and B depending on the involvement of ascending or descending aorta based on the Stanford system and into types I, II and III using DeBakey classification. The latest classification was proposed by the European Society of Cardiology in 2001. The authors present their own classification of distal aortic dissecting aneurysms that takes into account antegrade and retrograde dissection of the aorta, besides localization of proximal fenestration. Surgical strategies for the treatment of different variants of aortic dissecting aneurysms are considered.

[Present-day therapeutic policy in patients with chronic ischaemia of lower limbs: trans-Atlantic inter-society consensus].

The authors have reviewed the available literature dedicated to the development of the treatment policy for managing the patients presenting with lower limb ischaemia. Central to the work is the analysis of the latest guidelines on therapeutic policy to pursue in patients presenting with chronic ischemia of the lower extremities, namely the Trans-Atlantic Inter-Society Consensus Document. This is followed by a detailed discussion of the indications for surgical and endovascular operative interventions in various-type lesions of the aortofemoral and femoropopliteal segments. Summarized herein are the main trends and tendencies in the present-day strategy of managing the patient cohort concerned.

[Surgical treatment of patients with colorectal cancer and severe concurrent cardio-vascular diseases].

The study population comprised 14 patients, operated on account of colon cancer (n=2), sigmoid cancer (n=1), rectal cancer (n=6), synchronous rectal and prostatic cancer (n=1) and lung (n=1) and liver (n=2) colon cancer metastases. The diagnosed concurrent cardiovascular pathology was: coronary heart disease (n=8), valve disease (n=2), aortic aneurism (n=2), coronary heart disease combined with aortic aneurism (n=2). Simultaneous operations were performed in 3 patients, 11 patients were operated on consecutively. No deaths were registered after simultaneous operations. In the group of consecutive operations 2 patients had died of myocardial infarction and cardiac decompensation. 3 (21,4%) patients died of tumor relapse during the follow-up period. The rest 9 patients are under observation for 3 months to 10 years, 2 patients achieved a 5-year cancer-free survival time.

[Smooth muscle cell apoptosis in aneurysmal aortic lesion in the light of surgical treatment results].

Aortic aneurysm is a polyethiologic disease associated with high disability and perioperative mortality rate. The evolution of ethiopathogenesis of aortic aneurysm development is considered in the article. The findings of recent worldwide studies on immune status impact on the disease progress and the postoperative period are presented. All studies showed that 25% of patients had immune status disturbances accompanied by changes in the hemostasis system and high apoptosis index in blood serum and aneurysm tissue. Variants of clinical course of different aortic aneurysm forms and perioperative managements of patients aimed at prevention of possible complications are highlighted.

[Drug therapy of chronic venous insufficiency with Venza].

An open prospective study on the use of the drug Venza for complex variceal disease treatment was conducted. The study included 125 patients aged from 21 to 75. The outcome measures were: patient complaints and medical history, as well as Doppler ultrasound of lower limb veins, arteriovenous index (AVI) and leg circumference at the ankle level for the objective assessment of therapeutic effectiveness. Malleolar circumference decreased by average 0.8+/-0.3 cm. The drug therapy resulted in the regression of clinical signs (leg fatigue heaviness and edema, night palsies). Venza had a positive effect on all evaluated parameters of patient's quality of life. Its clinical effectiveness was estimated as "very good" and "good" in 27.5% and 57.5%, respectively. The study proved the Venza's effectiveness in treatment of patients with lower limb chronic venous insufficiency.

[A case of successful one-stage correction of abdominal aortic aneurysm and stenosis of the internal carotid artery in a 78-year-old patient]. / Sluchai uspeshnoi odnomementnoi korrektsii anevrizmy briushnoi aorty i stenoza vnutrennei sonnoi arterii u patsienta v vozraste 78 let.

Presented herein are the results of successful one-stage revascularization of the brain and reconstruction of the abdominal aorta in a 78-year old patient with infrarenal abdominal aortic aneurysm, the signs of rupture, stenosis of the left renal artery and multiple aortic arch lesions -- stenoses of both internal carotid arteries and both vertebral arteries. The sequence and technology of surgical intervention are described.

[Effect of aortic clamping on hemodynamics at reconstruction of the thoracoabdominal aorta]. / Vliianie perezhatiia aorty na gemodinamiku pri rekonstruktsii grudnoi i briushnoi aorty.

This paper describes an experience with monitoring and computerized follow up of the hemodynamic status in 60 patients at and right after reconstruction of the thoracoabdominal aorta. In addition to the routine control, measurements were made of the pressure in the large vessels and cavities of the heart, duration of each heart contraction and CI. The following parameters were computed automatically: the status of the ventricles for each heart contraction, resistance of the greater end pulmonary circulation, elasticity of the arterial, venous, pulmonary arterial and pulmonary venous reservoirs, also for each cardiac cycle. At the generally accepted monitoring the hemodynamic responses to the surgeon's manipulations on the aorta appear smoothed or are not visualized at all. The control of each heart contraction reveals the responses to application of the clamp and its removal from the aorta, with their hemodynamic significance being not questionable. Aortic clamping and clamp removal from the aorta are associated with the generalized response of the regulatory systems of the body. The slow and thoroughly controlled aortic clamping and graded, controlled blood flow restoration due to clamp removal as well as the use of sodium nitroprusside (trimetafan or isofluran are preferable) allow to avoid an abrupt stroke load of the left ventricle of the heart and, respectively, the generalized response of the regulatory systems of the body.

[Load tests in silent myocardial ischemia and latent heart failure in patients with IHD and intermittent claudication]. / Nagruzochnye proby pri bezbolevoi ishemii miokarda i skrytoi serdechnoi nedostatochnosti u bol'nykh IBS i peremezhaiushcheisia khromotoi.

244 patients with ischemia of the lower limbs were treated surgically in the specialized cardiovascular center. No lethal outcomes were reported because previously derived algorithm of detecting silent myocardial ischemia in patients with intermittent claudication and load tests (bicycle ergometry and drug stress tests) had allowed the surgeons to ascertain the extent of coronary damage and detect subclinical cardiac failure. Valid assessment of cardiac factors enabled the right choice between surgical and therapeutic methods and staging of the procedures.

[New aspects of the surgical treatment of aortic coarctation]. / Nekotorye novye aspekty khirurgicheskogo lecheniia koarktatsii aorty.

The article substantiates the urgency of the problem and shows the results of surgical treatment of coarctation of the aorta in 103 patients who were operated on in the recent 5 years. The operation of choice was resection of the coarctation with the formation of an end-to-end anastomosis (90.3% of operations). Establishment of the anastomosis by methods developed at the department makes it possible to achieve good results and avoid complications in the immediate and late-term postoperative periods. An anomalous arterial branch, a reduced branch of the 5th aortic arch called Abbott's artery, was ligated in 40% of cases. No fatal outcomes occurred in the last 5 years in surgical treatment of coarctation of the aorta.

[Results of surgical treatment of aortic coarctation in patients over 35 years of age]. / Rezul'taty khirurgicheskogo lecheniia koarktatsii aorty u bol'nykh starshe 35 let.

The authors studied the immediate and late-term results of surgical treatment of aortic coarctation in patients after the age of 35 years. The complications in surgical treatment, arterial pressure dynamics, the causes of deterioration in the patient's condition and the mortality were analysed. The main causes of deterioration of the patients' condition in late-term periods after surgery were: residual arterial hypertension (41.2%), ischemic heart disease (39.2%), aortic and/or mitral valvular diseases (25.5%), aneurysms of the thoracic aorta (11.8%). The expediency and efficacy of surgical treatment of coarctation of the aorta in patients over 35 years of age with stable regional arterial hypertension are proved.

[A new method of surgical treatment of recurrent aortic coarctation (aorto-aortic shunting from the ascending to the descending thoracic aorta)]. / Novyi metod khirurgicheskogo lecheniia rekoarktatsii aorty (aorto-aortal'noe shuntirovanie ot voskhodiashchei k niskhodiashchei grudnoi aorte).

The authors discuss the immediate results of 44 reconstructive operations performed for a second time on the descending thoracic aorta for complications of operative interventions conducted earlier for coarctation of the aorta. The high operative risk is connected with difficulties of rethoracotomy and the need to compress the thoracic aorta for a lengthy period of time. Operation for aorto-aortic shunting through right thoracotomy made it possible to avoid these difficulties. The immediate results of all 9 such operations were good.

[Surgical treatment of post-anastomosis aneurysm developed after reconstructive operations on the thoracic aorta]. / Khirurgicheskoe lechenie anevrizm anastomozov, voznikshikh posle rekonstruktivnykh operatsii na grudnoi aorte.

Twenty-three patients were examined and operated on for aneurysms of anastomoses which formed after reconstructive operations on the thoracic aorta for its coarctation (15), kinking of the arch of the aorta (4), traumatic aneurysms (2), nonspecific aortoarteritis (1) and dissecting aneurysm (1). The involved segment had to be repaired with a prosthesis in all operations carried out for the second time. In 30% of patients the course was complicated (aortopulmonary fistulas, false aneurysm with dissection of the descending thoracic aorta). Mortality was 57% in a complicated course and 6.3% in uncomplicated cases. The results of the operation were good in 18 patients.