[Surgical treatment of true aneurysms of permanent vascular access]. / Khirurgicheskoe lechenie istinnykh anevrizm postoiannogo sosudistogo dostupa.

Analyzed herein are the results of surgical treatment of true diffuse aneurysms of the permanent vascular access in 44 patients. Of these, there were 29 men and 15 women, mean age 48.1±2.3 years (19-78 years). The average time having elapsed since the formation of the native access was 109.4±9.5 months (12-276, median - 108 months). The indications for surgical treatment were as follows: haemorrhage including recurrent bleedings (3), thrombosis of the permanent vascular access (26), its dysfunction (5), high flow syndrome (3), large-size aneurysm with disordered function of the limb, pain syndrome or a pronounced cosmetic defect (7). In 14 cases, reconstruction was not performed. We carried out ligating operations, in some instances with partial removal of the aneurysm and establishing a new vascular access. 3 patients underwent resection of the aneurysm with replacement by a graft. In the remote period 1 patient at 46 months developed infection of the prosthesis, resulting in loss of the access. Follow up of the remaining 2 patients demonstrated satisfactory function of the vascular access at 6 and 60 months. 16 patients were subjected to total plasty of the aneurysm using autotissues. On a cylindrical template measuring 6 mm in diameter after dissection of excessive tissues along the posterior wall of the vein, an uninterrupted suture was formed followed by placing the formed transplant into a new bed. 11 patients underwent the operation according to the analogous technique, but the formed autotransplant was reinforced with a thin-wall exoprosthesis made of polytetrafluoroethylene up to 0.2-mm thick and 10 mm in diameter ('Ecoflon'). Two (12.5%) of 16 patients subjected to reconstruction of the aneurysm without reinforcement developed haemorrhage in the early postoperative period, and one developed thrombosis thus resulting in loss of the access. In-hospital patency amounted to 81.3%. In plasty with reinforcement, there were no complications in the early postoperative period. Long-term primary patency after total plasty without reinforcement at 1, 3, and 5 years amounted to 68.2±11.8%, 56.8±14.3%, and 22.7±13.7%, respectively, with secondary patency of 68.2±11.8% at the above-mentioned terms. In the majority of patients aneurysmatic transformation of the transplant occurred again in the remote period. Primary patency at 1, 3 and 4 years after plasty with reinforcement amounted to 80.8±12.2%, 80.8±12-2% and 60.6±19.8%, respectively, with the secondary patency rates of 90.9±8.7% at the above mentioned terms.

[Complications of permanent vascular access for haemodialysis]. / Oslozhneniia postoiannogo sosudistogo dostupa dlia gemodializa.

Permanent vascular access is the basis of renal replacement therapy by the method of programmed haemodialysis, on whose stable functioning depends the life of patients with end-stage renal disease. At the present time, there is significant deficit of scientific and methodological Russian-language literature on this problem, with no Russian consensus documents concerned. This article is a review of the contemporary world literature dedicated to the problem of permanent vascular access, including currently in force European (2018) and North American (2019) guidelines for good clinical practice, also discussing the problems of strategy and tactics of creating a permanent vascular access, monitoring its dysfunction, pathophysiology of functioning of arteriovenous fistulas. Presented herein are unified approaches to diagnosis and treatment of thrombolytic and haemorrhagic complications associated with the access, as well as local infectious and non-infectious complications. Special attention is paid to indications for the operation and rational therapeutic decision-making.

[Surgical treatment of patients with superior vena cava syndrome associated with permanent vascular access]. / Khirurgicheskoe lechenie bol'nykh s sindromom verkhnei poloi veny, assotsiirovannogo s postoiannym sosudistym dostupom.

Presented herein are two clinical case reports concerning surgical treatment for superior vena cava syndrome in patients suffering from end-stage renal disease and undergoing programmed haemodialysis. Initially attempted roentgen-endovascular recanalization turned out to be unsuccessful. The patients were then subjected to ipsilateral extrathoracic bypass grafting, which made it possible to preserve the vascular access for programmed haemodialysis and to relieve venous hypertension of the limb and the brain, as well as to improve quality of life. In one case, the duration of graft patency amounted to 6 months, during which time collateral circulation developed, with no relapse of venous hypertension observed, and the access functioned for a further 14 months. Thus, survival of the permanent vascular access increased by 20 months. In the second case, the duration of graft patency and functionality of the vascular access at the time of writing this article amounted to 12 months.

[Comprehensive physical antiedematous therapy in treatment of patients with lymphedema]. / Kompleksnaya fizicheskaya protivootechnaya terapiya v lechenii patsientov s limfedemoi.

Presented in the article is retrospective analysis of the results of treatment of patients with lymphedema. We treated a total of 33 patients with primary (n=6) and secondary (n=27) lymphedema. Stage II lymphedema was diagnosed in 18 (54.5%) patients, stage III lymphedema in 15 (45.5%) patients. The 33 patients had a total of 44 affected limbs (9 hands and 35 legs). All patients were subjected to comprehensive physical antiedematous therapy including: manual lymph drainage massage, formation of compression bandage, selection of individual class 3 plain stitch compression knitwear, special complex of therapeutic exercises, care of the skin of the affected limb. A positive effect was achieved in all cases. In patients with upper limb lesions the volume of the extremity decreased averagely by 1'235.0±283.7 cm3 (22.6% of the baseline volume, p<0.005), in patients with lower limb lesions it decreased by 2'712.0±350.3 cm3 (22.1% of the initial volume, p<0.005). The carried out therapeutic course resulted in improvement of quality of life at the expense of decrease of the deformity and improvement of the function of the limb, increase of the scope of movements in the joints, regression of trophic alterations, widening of possibilities of wearing footgear and clothes. A conclusion was made that comprehensive antiedematous physical therapy is an effective method of treatment of patients with limb lymphedema, making it possible to attain regression of trophic disorders and to improve patients' quality of life.

[Reconstructive operations in pathology of central veins, associated with vascular approach].

Presented herein are the results of treatment of 28 patients with stenosis/occlusion of central veins undergoing replacement therapy by means of programmed haemodialysis for terminal renal failure. The clinical symptomatology in all patients manifested itself by chronic lymphovenous insufficiency of the upper limb, dysfunction of the vascular access (14 patients, thrombosis of the vascular approach (5 patients), venous hypertension of the brain (4 patients). 17 patients had aneurysms of the vascular approach in the zone of puncture. In 18 cases for correction of the venous outflow we performed roentgenoendovascular angioplasty, including 3 cases in combination with stenting. Technical success amounted to 83.3% (15 of 18 cases). 13 patients underwent open reconstructive operations, including 5 cases of thrombectomy from the vein (in all cases failed one), in 8 cases bypassing operations (cross cephalic anterior jugular shunting - 5, subclavian-femoral bypass grafting - 1, transposition of the external jugular vein into the internal jugular vein - 1. In-hospital patency of bypasses amounted to 87.5% (7 shunts of 8). The remote results were followed up within the terms up to 43 months (averagely 12.3 ± 2.2 months). In the group of endovascular treatment more than half of patients (8 of 15) required secondary endovascular interventions. The cumulative requirements in re-do manipulations amounted to 52.4% during the first year and to 89.4% during the second year. The function of the approach was preserved in 93.3% of patients. Of the seven shunts patent in the early postoperative period, occlusion occurred in three cases at 1, 5 and 13 months. The 1-year patency amounted to 50.0%. The function of the approach was preserved in 75.0% of cases.

[The experience of 500 vascular reconstructions of the aorticfemoral segment using a miniaccess].

The immediate and long-term results of 500 reconstructive operations on the aorticfemoral segment using a miniaccess were analyzed. 443 patients suffered from the obliterative atherosclerosis and 57 were operated on the infrarenal aortic aneurism. The size of the surgical access was 5-12 sm (418 through laparotomy, 82 through the retroperitoneal access). The access enlargement was necessary in 5.0% of cases. The mean time of the operation was 166.6±7.8 min (90-255 min). Time of the aortic clamping was 26.2±1.5 min by the aortic by-pass and 32.3±4.5 min by the aortic resection. The postoperative leathality rate was 1.6%, the morbidity rate was 20.0% (local vascular complications 7.2%; local non-vascular complications 7.2%, systemic complication 7.6%). 5-year by-pass patency was 91.9±2.8%, the limb was preserved in 93.6±2.4%.

[Prevalence of an abnormal ankle-brachial index in the Republic of Tatarstan].

The ankle-brachial index (ABI) was determined in a total of 1,751 employees of industrial enterprises of the Republic of Tatarstan aged from 45 to 84 years old (mean age 55,3 ± 0,14 years). An abnormal ABI was registered in 5,1% of the examined people (4,1% in the age group from 45 to 55 years, 5,4% in 56-65-year-old patients, and 12,1% in subjects over 65 years (p=0,001). An abnormal ABI was registered in 8.3% of men, and 3,1% of women (p=0,000), in 4,1% of rural population, 5,9% (p=0,138) of urban population, in 14,8% (p=0,000) of smokers, and in 45,4% (p = 0,000) of patients with a history of a cardiovascular event.

[Rational minimally invasive nature in surgical reconstructions of the abdominal aorta].

Based on a meta-analysis of the literature and own experience in a total of 490 reconstructions of the aortofemoral segment using a miniapproach, the authors carried out a comparative analysis of the main minimally invasive methods employed for treatment of the pathology concerned.

[Objective criteria for the invasive nature of a mini-approach in aortofemoral reconstructions. A prospective study].

The authors carried out a prospective study of the invasive nature ofaortofemoral reconstruction performed via the standard routine laparotomy (StLT, Group I, n 10) and minilaparotomy (MLT, Group II, n = 10). It was determined that the objective criteria for the invasive degree of the intervention were less pronounced in the group of the patients operated on through the MLT, with the main differences manifesting themselves to a greater extent in the early postoperative period. Despite statistically significant differences of the creatinphosphokinase (CPK) level as a marker of a parietal injury (562 U/I in Group 1, 243 U/I in Group II, P = 0.005), the concentration of Cortisol increased dramatically during the operation (by 288 and 162%, respectively) with a statistically insignificant deference between the groups (P = 0.08). Alterations in the vegetative status (determined by cardiointervalography) in the intraoperative period were ofa variously directed variable character, not differing between the groups. However, normalization ofthese parameters in the postoperative period occurred more rapidly in MLT. Group IH patients were noted to restore earlier the function of the gastrointestinal trapt with a less pronounced pain syndrome tested by the visual analogue scale, especially on postoperative days 2 and 4 (p<0.01 and. Hence, reconstruction of the infrarenal aorta through the MLT is characterized by a lesser invasive nature, with the above mentioned differences being more pronounced in the early postoperative period, since the main intraoperative factors of the invasion depend to a lesser extent on the approach size.

[Minimally invasive surgery of the infrarenal aorta].

Over five decades having passed since the first report of J. Oudot on grafting of the abdominal aorta, reconstructive operations on the aortofemoral segment have become amongst the methods most commonly used in angiosurgery. However, despite the progress achieved in anaesthesiology, critical care medicine and surgical techniques, the traumatic nature of these interventions is still high, which predetermines the perioperative lethality rate amounting to 2-5 %. Certain progress has been related to the introduction of endovascular methods of treatment. However, these techniques have failed to solve the problem because of the presence of certain contraindications and limitations thereof. Further search for ways aimed at improving the outcomes of management of patients presenting with pathology of the infrarenal aorta has led to the introduction of minimal-access surgery (MAS) widely used since the 1980's in various areas of surgery. The present article reviews the history and state of the art of minimally invasive surgery of the infrarenal aorta, giving a comparative evaluation of the three main techniques currently used, i. e., an open minimal access, "total" endovideosurgery, and a video-assisted minimal access. Also reflected herein are the main technical problems arising and encountered during these operations, and disadvantages of each of the methods. Special attention is paid to the problem concerning technical support of the minimally invasive operations, and limitations to the application thereof.