[Reconstruction of caval veins]. / Rekonstruktsiya polykh ven.

OBJECTIVE: To study the possibilities and results of reconstruction of caval veins. MATERIAL AND METHODS: We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins. RESULTS: All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged. CONCLUSION: Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.

[Some aspects of iatrogenic vessel injury]. / Nekotorye aspekty yatrogennykh povrezhdenii sosudov.

Iatrogenic events made up 1-10% of in-hospital mortality. Currently, iatrogenic vascular injuries are described for almost all surgical areas. Incidence of iatrogenic vascular injuries is gradually increased that is primarily associated with high number of percutaneous endovascular interventions. Surgical treatment of patients with iatrogenic vessel injuries is extremely difficult. This is due to sudden development of this complication, severe clinical state of the patient associated with underlying disease, acute massive blood loss, as well as insufficient experience of surgeon in urgent vascular surgery. Simple lateral or circular suturing is not always possible to restore the vessel integrity. Vascular replacement including non-standard vascular reconstructions are often required. Prevention of iatrogenic vascular injuries is also insufficiently described in the literature. Most manuscripts devoted to iatrogenic vascular injuries are usually represented by case reports or small sample. Thus, it is impossible to identify the main measures for prevention of iatrogenic injury.

[Non-standard method of reconstruction of the abdominal aorta for a giant aneurysm].

Abdominal aortic aneurysms are encountered predominantly in elderly patients suffering from severe concomitant diseases. Therefore, the rate of various complications associated with resection of aortic aneurysm amounts to 30%, with lethality in separate cohorts of patients reaching 43.7%. According the authors' opinion, in the development of intra- and postoperative complications of special importance is the duration of aortic clamping accompanied by severe haemodynamic alterations in coronary, cerebral and renal vessels. These changes are key moments in the development of fatal outcomes. In order to reduce the duration of aortic clamp the authors suggested a non-standard surgical technique of prosthetic repair of the abdominal aorta. Presented herein is a clinical case report illustrating this technique. The patient operated on according to this technique was discharged in a satisfactory condition with no serious postoperative complications. The proposed non-standard surgical technique makes it possible to reduce the duration of aortic cross-clamping in resection of an aneurysm by 10-12 minutes.

[Combined methods of treatment the congenital arterio-venous fistulas of peripheral vessels].

A 10-year experience and results of combined methods of surgical treatment of arterio-venous fistulas of peripheral vessels in 50 patients were analyzed. The patients were systematized on the basis of existing classifications, clinical manifestations of the disease, methods of invasive (ultrasound dopplerography and duplex scanning) and invasive (angiography) examinations. According to many authors no one of conventional methods of surgical treatment of arterio-venous fistulas which are used singly can be effective and must not be recommended as the most optimal. Stepwise employing of traditional operations and endovascular techniques are the main conditions for preventive measures of ischemic disorders in the limbs.

[Present-day possibilities of surgical management of tumour-like forms of arteriovenous angiodysplasias].

Described herein is the treatment policy pursued in a relatively uncommonly encountered variant of congenital vascular pathology, i. e. arteriovenous angiodysplasias. We operated a total of twenty patients presenting with various localization of the pathology concerned. The patients average age amounted to 18 ± 8.6 years. In order to make the diagnosis of the disease and to accomplish the tactical missions we used duplex scanning and angiography. According to the opinion of the authors, in this form of angiodysplasias using any method of treatment independently cannot be efficient. Arteriovenous angiodysplasias were treated by a combined method including endovascular embolisation or sclerotherapy of the afferent vessels and surgical removal of vascular formations. The use of such therapeutic policy makes it possible to attain positive results in 75% of patients.

[The combined strategy in treatment of lymphangiodysplasia].

The experience of treatment of a rare form of pathology of the lymphatic system was analyzed. The surgical tactics, depending on both the dimentions and the form of lymphangiodysplasia, were described. The absence of the pain sensitivity and large tumor size were the main reason of medical help seeking for the patients on the late stages of the disease. To minimize the volume of the intraoperative bleeding, the authors recommend skeletization of the magistral arteries or their embolisation as a preliminary step before the lesion's surgical excision. The method proved to be extremely effective in two patients with giant lymphagioma.

Revascularization in distal lesions of upper extremity arteries.

A study was made of the course of ischemia and hemodynamic disorders in 53 patients with occlusion of the distal arterial system of the upper extremities. Circulation was examined by ultrasound Doppler, tetrapolar rheology, transcutaneous oxymetry and angiography. Critical ischemia was discovered in 58.5% of patients. In occlusion of one of the forearm arteries, extremity circulation was made for. Circulatory decompensation was recorded in occlusion of both forearm arteries with intact distal bed and non-functioning palmar arches of the hand as well as in lesions of hand and finger arteries. All 53 patients were operated on, 66 operations were accomplished using magnifying optic appliances. Provided the distal bed was well preserved, use was made of direct revascularization techniques (36) whereas non-standard methods were employed in the event of its obliteration: arterialization of the outlets of the subcutaneous veins of the hand and autotransplantation of the greater omentum (30). Beneficial results were obtained in 91.5% and unsatisfactory in 8.5% of patients. The lethality accounted for 1.2% while the incidence of amputations was quoted as 5.7%. Good results offer the period as long as 5 years were well preserved in 87.6% of patients. Our experience indicates the efficacy of the use of revascularization techniques for the treatment of different versions of occlusion of the distal segments of upper extremity arteries.

Traumatic injuries of the popliteal and tibial arteries: limb ischemia and problems of surgical management.

This paper analyzes the results of examination of 106 patients with traumatic injuries of the popliteal (n=36) and leg arteries (n=70) including gunshot (n=48), punctured and incized (n=32), contused-crushed (n=17) wounds and blunt (n=9) traumas. Sixty-two patients were admitted within 8 hours of injury and 20 within 8 to 24 hours, 24 patients within 1 to 15 days. Sixty-five patients had been rendered first aid at other medical institutions. It is to be noted that the prehospital diagnostic and tactic errors had been made in 67.7% of cases. In the patient group with injuries of the leg arteries, the severity of ischemia correlated with the number of the injured arteries and in the group of patients with popliteal artery injuries, there was a relationship between the severity of ischemia and the character of injury. In injury of the popliteal and leg arteries, severe limb ischemia was present in 72.2 and 34.3% of cases respectively. The surgical management was worked out depending on the severity of the patient general condition and the degree of limb ischemia. Primary limb amputation was performed in 17 (16%) patients; the indications for it were moist gangrene, severe traumas with major destructions and defects of other anatomic structures (inadvisability of revascularization), critical condition of the casualty, severe circulatory decompensation observed even in the early times of referral, when it was necessary to save the patient's life. Different surgical interventions were undertaken in 89 patients: ligation of the vessel in the event of one artery injury (24), revascularization (61) and fasciotomy, hematoma evacuation and bone reposition (4). Eleven (10.4%) patients underwent secondary amputation. Beneficial results with complete circulatory compensation were obtained in 78 (73.6%) patients. The total incidence of amputation and lethality accounted for 26.4%.

[Surgical strategy in traumatic lesions of the popliteal artery]. / Khirurgicheskaia taktika pri travmaticheskikh povrezhdeniiakh podkolennoi arterii.

An examination and treatment of 32 patients with injured popliteal arteries are analyzed. Among the etiological factors there were gunshot wounds (16), crushed (4), punctured-incised (7) and blunt (7) traumas. Combined injuries of the popliteal vein were diagnosed in 12 patients, and injuries of the bones--in 16 patients. Errors were made in 19 cases at the prehospital stage: late diagnosis of the injury (11), transporting the patient in the state of shock (5), ligation of the popliteal artery (3). The term of extremity ischemia more than 8 hours was noted in 13 admitted patients. Decompensation of circulation was diagnosed in 22 patients. The primary amputation was performed on 6 patients with moist gangrene. Vascular reconstructions were made in 26 cases including the autovenous prosthesis and circular suture. Secondary amputations were fulfilled to 6 patients. Three patients died. Good results were obtained in 20 cases.

Surgical management of traumatic injuries to the tibial arteries.

Altogether 60 patients with traumatic injuries to the tibial arteries were entered into the study. Twenty-four patients presented with gunshot, 24 with stab and incised, 10 with contused and lacerated wounds, and 2 patients had blunt traumas. Thirty-nine patients were admitted to the clinic within the period as long as 8 hours since the time of wounding, 9 patients within 8 to 24 hours, and 12 patients within the period as long as one to 15 days. 39 patients had been rendered first medical aid at other treatment institutions. It was established that prehospital diagnostic, tactic and technical errors had been made in 25 of the 39 patients. All the patients were distributed into three groups: group I (n=8) included patients with isolated injuries of one of the tibial arteries; group II (n=11) with injuries of two arteries and group III included patients with damage to all three arteries. In group I, circulation remained made for irrespective of the times of ischemic state existence. In groups II and III, all the patients demonstrated circulatory decompensation. Surgical management depended on the severity of the general condition and the degree of limb ischemia. Primary amputation was indicated to 11 (18.3%) patients (humid gangrene was diagnosed in 5 patients, severe trauma with major defects of soft tissues and bone fractures in 6 patients). The remaining 49 victims underwent different surgical interventions such as ligation of the vessel at injury to one artery (23); revascularization (22); fasciotomy, hematoma evacuation and reposition of the bones in an isolated form (4). Five (10.2%) patients required secondary amputation. Beneficial results with complete circulatory compensation were obtained in 44 (73,3%) patients. The overall amputation rate accounted for 26.6%.