[Vector mapping of deformation and blood flows in patients with ascending aortic aneurysm]. / Vektornoe kartirovanie deformatsii i potokov krovi u patsientov s anevrizmoi voskhodiashchei aorty.

The authors performed clinical studies based on modelling of an ascending aortic aneurysm in 37 patients and 10 apparently healthy subjects. Echocardiography was carried out in the B-mode using the Vivid E9 device (USA, GE). The linear dimensions of the aorta were assessed at three points - in the immediate vicinity of the valves, in the area of the maximum dilatation and in the area of decreased dilatation with registration of blood flow velocity in the aorta. The aortic walls were contoured with the division of equal intervals into 4 portions in order to obtain longitudinal shear deformation velocity during the cardiac cycle. We worked out a system of assessing the velocity vector fields with the help of transthoracic echocardiography in patients with an ascending aortic aneurysm, based on registration of blood flows, which made it possible to obtain the components of velocity. We also determined an optimal method of assessing turbulence in the aorta taking into account the direction of the vectors. Obtained were the numerical data of aortic wall deformation velocity in the longitudinal direction and calculation of the weighting function with the distinction between pathology and the norm. Based on the deformation, the distance between the registered points, and the movement of the vascular wall, we determined the reference values of blood flow velocity inside the aorta and immediately close to its walls.

[Stagewise hybrid method of treating a patient with connective tissue dysplasia, aortic aneurysm, and distal dissection]. / Étapnaia gibridnaia metodika lecheniia bol'nogo s soedinitel'notkannoi displaziei, anevrizmaticheskoi bolezn'iu aorty i distal'nym rassloeniem.

Presented herein is a clinical case report concerning the use of a hybrid technique in stagewise surgical management of a patient with distal dissection and an aneurysm of the thoracoabdominal portion of the aorta. The patient at high risk with the connective tissue dysplasia syndrome had a past medical history of prosthetic repair of the descending thoracic aorta with type-1 haemodynamic correction. Three years later, the findings of computed tomography demonstrated fenestration in the area of the distal anastomosis, a patent false channel, and an increase in the diameter of the unoperated thoracoabdominal portion of the aorta. The first stage consisted in performing prosthetic repair of the infrarenal portion of the aorta by means of the multibranched Coselli thoracoabdominal graft, followed by 'switching' the visceral branches into the formed prosthesis. 14 days later, the second stage included stenting of the dilated suprarenal portion of the aorta. The patient was discharged on day 9 after the second stage of the operation. This clinical case report demonstrates that a hybrid method of treatment may by an alternative to an open operation in high risk surgical patients presenting with severe concomitant somatic pathology.

[PHARMACOLOGICAL POSTCONDITIONING BY SEVOFLURANE DURING CARDIAC SURGERY.]

BACKGROUND: Optimization of myocardial protection during cardiac surgery with a long period of anoxia infarction using sevoflurane postconditioning of myocardium. THE AIM: to develop the optimal pharmacological postconditioning protocol with sevoflurane for infarction patients ,undergoing cardiac surgery. MATERIALS AND METHODS: Two groups were formedfor this study: CON] 00 (n-32) with aortic cross-clamping time 114±15 min and SEV100 group (n-34), where the myocardium anoxia was 119±22 minutes. According to previously developed in the pilot study Protocol, we added sevofturane in the circuit of extracorporeal circulation in a dose of 2.0 vol. % 20 minutes before removing the clamp from the aorta and the first 20 min of reperfusion in the group SE V100. In the group CON1 00 pharnacological postconditioning wasn't conducted. To assess the adequacy of the cardioprotection against ischemic damage in operated patients, we used the following clinical and laboratory parameters: changing the level of troponin T; the concentration of lactate and glucose as a marker of severity of anaerobic metabolism; concentration of proinflammatory cytokines IL-6, IL-8, TNF-alpha in blood serum as reperfusion injury markers. Also we used the registration of central hemodynamics data: measuring the mean invasive blood pressure; central venous pressure; Cardiac output was measured by the method of transesophageal echocardiography TEEcho-CG, calculated left ventricular ejection fraction by Simpson. We evaluated the clinical course of the perioperative period: incidence ofperioperative myocardial ischemia; the need and the duration ofuse of cardiotonic drugs in the perioperative period; the incidence of reperfusion arrhythmias; the frequency of self-recovery heart rate. RESULTS: According to the results of anaerobic metabolism markers, we can conclude that the period of the myocardium anoxia ofpatients in both groups experienced no significant difference. However; a completely different pattern was observed when comparing the proinflammatory cytokines, such as IL-6, IL-8, TNF-a. This confirms that the group SEV] 00 survived the reperfusion is much better than the group CON100. Instrumental examination also showed that the group ofpatients in which pharmacological postconditioning with sevofturane was held signficantly better suffered ischemia and reperfiision injury compared to control group. Self-recovery heart rate after removing the aorta clamp in the group CON100 was observed in 81%, in group SEV100 same - 93%. Similarly, the frequency of myocardial ischemia episodes on the ECG in reperfusion period was two times lower in the group SEV100 compared with group CON100 - 5.8% and 12.5% respectively. Reperfusion arrhythmia is almost 3 times more frequent in the group CON100 - 21,8%, in the group SEV100, where he conducted pharmacological postconditioning with sevoflurane is 8.8%.. CONCLUSION: Combined with sevoflurane cardioprotection FPC has a much better resistance to myocardial ischemia-reperfusion injury in patients with myocardial infarction time over 100 minutes than monoprotection with cardioplegic solution "Console ". This method can be recommended as an additional method ofprotection against myocardial ischemia-reperfusion injury.

[Endoprosthetic repair of the abdominal aorta in patients with infrarenal aneurysm and unfavourable anatomy of its proximal neck].

Analysed herein are immediate and remote results of endoprosthetic repair of the abdominal aorta in patients with unfavourable anatomy of its proximal neck. Group I (Study Group) was composed of 31 patients with unfavourable anatomy of the proximal neck, the control group (Group II) comprised a total of 52 patients with no unfavourable anatomical factors. The criteria of assessment were as follows: technical success, adequate position of the endograft, frequency of the development of various endoleaks, duration of the operation and hospital stay, lethality in the remote period, and necessity of secondary interventions. Technical success of endoprosthetic repair was achieved in 100% of patients in the both groups. An adequate position by the proximal end of the coated portion of the endograft was observed in 27 (87.1%) patients of Group I and in 51 (98.1%) patients of the control group (p=0.08). Secondary postdilatation of the endograft's body in the proximal neck was statistically more often performed in the study group of patients. The duration of the operation and hospital stay in the compared groups had no statistically significant differences. In the remote period, patients with unfavourable morphology of the proximal neck were found to develop type I-A endoleaks into the cavity of the aneurysm. By other evaluated criteria such as the total survival rate, secondary interventions, graft migration, type I-B, II and V endoleaks no statistically significant differences were revealed. It was concluded that endoprosthetic repair of the abdominal aorta in patients with unfavourable anatomy of the proximal neck of the aneurysm is associated with admissible immediate, short- and long-term outcomes. Longer follow up is required in order to more adequately asses the reliability of the obtained findings.

[Surgical treatment of a patient with giant false aneurysm of xenopericardial conduit of the ascending aorta].

The article deals with a clinical case report concerning successful secondary surgical intervention for a giant pseudoaneurysm of the xenopericardial conduit of the ascending aorta in a patient with type A chronic aortic dissection, with a history previously endured prosthetic repair of the ascending aorta and aortic valve for acute dissection. The patient underwent was subjected to repeat prosthetic repair of the aortic valve and ascending aorta according to the Cabrol's technique. The postoperative period was uneventful. The function of the aortic valve prosthesis after surgery was satisfactory. The control multispiral computed tomography showed that reconstruction zone was without deformities, with the ostia of coronary arteries patent. On day 15 postoperatively the patient was discharged from hospital to undergo rehabilitation with recommendations concerning the subsequent stage of surgical treatment. The conclusion was drawn that despite life-threatening disease and an extensive scope of reconstruction correctly chosen surgical policy makes it possible to adequately carry out the necessary operation with a good outcome.

[Hybrid technology in repeat operation of a patient with aortic arch aneurysm and type A chronic aortic dissection].

Presented herein is a clinical case report concerning successive use of hybrid technology in secondary surgical treatment of a patient with a progressing aortic arch aneurysm and aortic insufficiency, type A chronic aortic dissection after the primary operation of plasty of the aortic valve with prosthetic repair of the ascending aortic portion for type A acute dissection. The patient underwent hybrid operation: prosthetic repair of the aortic valve with mechanical prosthesis "Carbomedics", prosthetic repair of brachiocephalic branches by means of synthetic prostheses "Vascutek" with their switching to the prosthesis of the ascending aorta, stenting of the arch and descending portion of the aorta. The duration of the postoperative hospital stay amounted to 15 days. The control multispiral computed tomography with intravenous contrasting showed that the reconstruction zone was with no deformities, with the stent graft expanded, and no leaks noted. The conclusion was made that further improvement of hybrid technique can make it a true alternative to classical surgical operations in this severely ill cohort of patients. The presented clinical example demonstrates that simultaneous hybrid surgical intervention is the most correct approach in the given situation decreasing lowering the risk of the development of complications in both immediate and remote postoperative period.

[Valve-sparing technique for type a aortic dissection with insufficiency of aortic valve].

This article describes clinical experience of surgical treatment of aortic insufficiency in type A aortic dissection using valve-sparing technique. Results of treatment are presented.

[Clinical management of patients with abdominal aortic aneurysms combined with coronary artery disease and multifocal atherosclerosis].

We have analyzed clinical management of 137 patients with atherosclerotic aneurysms of the abdominal aorta combined with coronary artery disease treated during last 10 years in the First Cardiac Surgery Department (Surgery of the Aorta and its Branches) of the Petrovsky National Research Center of Surgery. All patients were subjected to surgery involving both vascular regions: in 130 patients (94.9%) the procedures were staged while 7 patients underwent myocardial revascularization simultaneously with the reconstruction of the abdominal aorta from the minimal access. According to our results staged procedures are safer for patients with atherosclerotic aneurysms of the abdominal aorta combined with coronary artery disease given the organism's limited capacity due to age and comorbidities. Endovascular repair techniques applied both to the coronary arteries and to the abdominal aorta should be always regarded primarily as a gentle form of intervention. In cases where open surgery is required one should try to avoid blood loss, reduce the duration of the procedure and use minimal access surgery when applicable. The overall mortality rate in patients treated for this disorder over the last 10 years was 2.1%.

[IgG4-related chronic periaortitis with retroperitoneal fibrosis].

The paper describes a case of IgG4-related chronic periaortitis in a 56-year-old man. Computed tomography revealed stenosis of the abdominal aorta and both common iliac arteries due to calcified atherosclerotic plaques, in this connection, bifurcation aorta-common femoral bypass surgery was performed. Intraoperatively, a solid retroperitoneal mass intimately connected with the walls of vessels was revealed in the retroperitoneal space around the aorta and iliac arteries. Histological examination ascertained rough fibrous connective tissue growth, a marked lymphoplasmacytic infiltration with an admixture of eosinophils, and formation of lymphoid follicles with germinal centers. Immunohistochemical examination revealed the plasma cell expression of CD20, IgG, IgG4, and kappa and lambda light chains in the inflammatory infiltrate. Because of active immune inflammation, further conservative therapy was recommended.

[Case of successful prevention of multiple organ dysfunctions in 74 years old patient with sepsis after Crawford surgery complicated with pleural empyema, chest wall tissues infection and osteomyelitis of ribs].

The article deals with a clinical case demonstrating that patient's elderly age is not an absolute contraindication for complex surgery in spite of high risk of postoperative complications. Early diagnostics, target treatment of the infection cite with vacuum-assisted therapy for wounds and the treatment of infectious complications based on individual characteristics of elderly patient with sepsis as an outcome of prosthetic thoracoabdominal aortic repair allowed avoiding multiple organ dysfunctions in the patient.

[One-stage carotid and coronary artery surgeries in the treatment of multifocal atherosclerosis].

One of the most severe forms of multifocal atherosclerosis often accompanied by heart attacks and strokes is concomitant coronary and carotid artery disease. Unfortunately to date there have been no qualitative randomized trials allowing us to develop a unified optimal approach to the treatment of this pathology. We have analyzed the treatment of 128 patients with coronary artery disease and atherosclerotic carotid stenosis operated on the two vascular territories over the past 10 years in the Department of Surgery of the Aorta and its Branches of the Petrovsky National Research Center of Surgery. One-stage reconstruction in two arterial basins was performed on the majority (75%) of patients. Other patients underwent multistage procedures including the use of endovascular techniques. The absence of any significant differences in mortality and postoperative complications between groups subjected to single- and multi-stage treatment, doubtless reduction of risk of vascular complications in uncorrected arterial bed by one-stage reconstruction allows us to consider this treatment strategy the method of choice in the management of this pathology. Overall surgical mortality of patients with combined coronary and carotid artery involvement subjected to our strategy was 0.8%.

[Sevoflurane optimal dosage estimation for myocardium pharmacological postconditioning: an experimental study].

We estimated the optimal dosage of inhalation anesthetic sevoflurane, for the maximum cardioprotective effect with minimal angioparalytic action. 25 pigs were included in this study, they were divided into 5 groups, depending on the sevoflurane dosage used for pharmacological postconditioning (PPC): control group - PPC has't been conducted, a group of PPC 0.5 - sevoflurane PPC in a dose of 0.5 V%, a group of PPC 1.0 - sevoflurane PPC in a dose of 1.0 V%, a group of PPC 1.5 - sevoflurane PPC in a dose of 1.5 V%, a group of PPC 2.0 - sevoflurane PPC in a dose of 2.0 V%, a group of PPC 2.5 - sevoflurane PPC in a dose of 2.5 V%. Ischemia was simulated by left coronary artery crossclamping. Further PPC was held according to the following Protocol: 20 min before left coronary artery clamp off and first 20 min of reperfusion sevoflurane was given into CPB circuit. Myocardial ischemia period was 60 min in all groups. It was found and experimentally proved that the optimal sevoflurane dosage for PPC is 2 V%

[The thoracic aorta aneurism stenting].

27 patients with thoracic aortic aneurism with dissection type III were operated on and stented. The mean age was 56±11,17 years. Men were 24, women 3. 1 patient developed intraoperative stent-graft leakage type IV, and 1 - type II. Both cases needed no additional manipulations. Minimal invasiveness of the procedure and pain absence allowed early activisation of patients. 2 patients had postoperative paraplegia, which was successfully treated by spinal drainage. There were no lethal cases. The long-term follow-up showed no leakage on CT scans; 11 patients demonstrated complete closure of false canal of the stented segment. The overall survival rate was 92.6% after 60 months of follow-up. Unfavorable results were registered in 29.6%.

[Single-step surgical management of lesions of the ascending aorta and aortic arch, coronary and carotid arteries in a male patient with multifocal atherosclerosis].

Described in the article is a clinical case report concerning single-step surgical management of a male patient presenting with multifocal atherosclerosis accompanied by an aneurysm of the ascending aorta and proximal segment of the aortic arch combined with lesions of the coronary and brachiocephalic vessels, thus showing a possibility of surgical treatment in this cohort of patients, if completely and timely diagnosed. Performing a one-stage operation without aggravating the surgical intervention makes it possible to decrease the risk of complications of both the heart and brain in the intra- and postoperative periods.

[Hybrid reconstructive interventions in distal aortic dissection].

The authors report herein the findings of a prospective study including a total of 26 patients presenting with distal aortic dissection and treated by prosthetic repair of the descending portion of the thoracic aorta. The patients were subdivided into two groups, with Group One comprising 15 patients having the blood flow directed into the true channel and Group Two composed of eleven patients subjected to directing blood flow into the both channels. Twelve (80%) Group One patients were found to have thrombosis of the false channel and an increase in the true channel's diameter. Five (45%) Group Two patients in the remote period developed dilatation of the abdominal aorta requiring distal prosthetic repair in three of them. A further two patients intraoperatively received uncoated stentgrafts (Djumbodies Dissection System, Saint Come Chirurgie, France) inserted into the distal portion of the thoracoabdominal aorta in order to provide adequate perfusion of the visceral branches. It was shown that local prosthetic repair of the descending thoracic aorta is appropriate only in case of the blood flow directed into the true lumen and expansion of the compressed true channel of the aorta distal to the reconstruction site by means of stenting resulted in better haemodynamic outcomes.