[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.

[30th Annual Meeting of the European Society for Vascular Surgery (Copenhagen, Denmark, september 28-30, 2016)]. / 30-i kongress evropeiskogo obshchestva sosudistykh khirurgov (Kopengagen, Daniia, 28-30 sentiabria 2016 g.).

The article is a brief review of the proceedings of the 30th Annual Meeting of the European Society for Vascular Surgeons, held on September 28-30, 2016 in Copenhagen, Denmark. The papers presented reported the results of managing patients with pathology of carotid arteries, aortic aneurysms, pathology of peripheral arteries, also discussing current achievements and prospects of methods of treatment of arterial and venous diseases.

[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.

[Surgical treatment of superior thoracic outlet syndrome].

The authors present immediate and long-term results of treatment of 117 patients with superior thoracic outlet syndrome (STOS). There were different reasons for compression of neu- rovascular fascicle in outlet of the thorax. The costaclavicular syndrome was a reason in 48 patients, additional cervical ribs had 36 patients. Skalenus syndrome was noted in 26 cases, rudimentary cervical ribs or hypertrophy of cervical vertebrae C7 had 7 patients. Raynaud's syndrome took place in 19 cases. The required volume of diagnostic procedures and surgical treatment of STOS were determined according to the cause of the syndrome. Differentiated approach to the different forms of STOS was used in relation to dominant symptoms of the disease and reasons for compression of neurovascular fascicle. This allowed getting positive results in majority of patients (90,4%) in long- term period.

[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.

[Anticoagulant therapy in comprehensive treatment of acute thrombosis of lower-limb deep veins].

The authors analysed the findings of examination and treatment of 61 patients presenting with acute thrombophlebitis of lower-limb deep veins, also investigating the risk factors for the development of acute thrombophlebitis. Of these, 54 (88.5%) patients were found to have various risk factors. During treatment we studied efficacy of anticoagulant therapy, also carried out examination of the blood coagulogram. Depending on the method of anticoagulant therapy, all patients were subdivided into two groups: Group One patients (n=30) received a combination of heparin and warfarin and Group Two patients were given monotherapy with heparin alone. It was determined that combined administration of two anticoagulants resulted in prolongation of the value of the activated partial thromboplastin time by 20% from the normal one in the majority of those receiving it (n=22, 73.3%), whereas in Group Two patients it was observed only in 12 (38.7%) patients. The values of the international normalized ratio in Group One patients were within the therapeutic (2.0-3.0) range, while in Group Two patients they were less than 2.0. There were neither haemorrhagic nor thrombolytic complications associated with administration of anticoagulants in either group. A combination of two anticoagulants turned out to be more effective for reaching adequate and safe hypocoagulation. The authors also worked out a therapeutic regimen and policy of follow up of patients presenting with acute thrombophlebitis. The comprehensive set of treatment included an effective route of paransal administration of the therapeutic mixture, favourably influencing the course and regress of the inflammatory process. The immediate results were as follows: good and satisfactory outcomes amounted to 93.4%, and poor results were noted in 6.6%. The short-term results were studied for up to 6 months revealing that 83% of patients had evidence of recanalization of the thrombosed veins, and only 17% demonstrated chronic occlusion.

[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 efficacy of arterio-venous fistulas in the treatment diffuse arterial diseases].

The experience of treatment of 32 patients with diffuse peripheral arterial diseases was analyzed. All patients underwent the by-pass surgery with the formation of unloading arterio-venous fistulas. Indications to the formation of A-V fistula was the high peripheral resistance of the vascular wall. 4 variants of by-pass were used: the side-by-side by-pass n=14; the preanastomotic adjuvant arterio-venous shunt n=7; and 2 original author modification. The analysis of the results demonstrated no statistical difference between A-V shunts modifications. However, the methods, proposed by the authors has some advantages due to the higher increase of the perfusion area.

[Substantiation of surgical decision making in congenital lesions involving the inguinal major vessels n injection drug abusers].

The article is dedicated to surgical policy pursued in lesions involving femoral major vessels in the inguinal region, having developed due to long-term abuse of injection narcotic drugs. Analysed herein are the outcomes of surgical management of thirty-one patients presenting with a pulsating haematoma and inguinal pseudoaneurysms of post-injection aetiology. According to the authors' opinion, choosing the appropriate scope of the would-be operation is too complicated largely due to peculiarities of the pyo-necrotic process in this zone. Revealed and systematized characteristic of this category of risk factors that pose a real threat of severe consequences when any type of surgery. The authors recommend using only 2 categories of operations: ligation of damaged vessels in the groin area as an independent operation and ligation of vessels with the restoration of blood flow through lateral bypass autovein. Indications for their use, particularity of performing the ligated operations in the inguinal region was given.

[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.

[Successful surgical repair of aortic arch torsion and aneurysm].

Described herein is a rarely encountered in clinical practice case regarding surgical management of pathological tortuosity of the aortic arch with a simultaneously present aneurysm thereof. The defect was surgically corrected in the setting of extracorporeal circulation. The tortuous and aneurysmatic aortic arch was resected within the boundaries of the healthy tissues, duly followed by establishing an end-to-end anastomosis between the edges of the resected aorta.

[Successful surgical treatment of veritable internal carotid aneurysm due king-king].

In the report authors had shown the clinical observation (case) of surgical treatment of the patient with veritable lateral aneurysm of right internal carotid artery appeared due of its king-king.

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.

[Surgical management of thromboses and aneurysms of the reconstructed vessels].

This paper analyses the results of reoperations in 52 patients with thromboses (n=42) and aneurysms (n=10) of the reconstructed vessels. The main causes of their development were progression of vascular disease and suppuration of a surgical wound. No relationship was established between complications and the type of suture materials. The diagnosis of the disease was made on the basis of the clinical data and duplex scanning. The operation of choice for thromboses of aortofemoral grafts was retrograde thrombectomy with reconstruction of the distal anastomosis, which was performed in 24 patients. Despite the controversial data on the possibility of thrombectomy from vein grafts the authors could accomplish it in 6 of 10 patients with thromboses of the femoro-popliteal vein bypasses. It is emphasized that the basic component of reoperations for occlusions of the femoro-popliteal segment lies in the formation of a tension-release arterio-venous fistula. In the postoperative period, rethrombosis of the reconstructed vessels occurred in 2 patients, arrosive bleeding in 3; limb amputation was performed in 3 patients, one of whom died from peritonitis.

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%.

[Symptoms, diagnosis and surgical treatment of posttraumatic arterial occlusion]. / Klinika, diagnostika i khirurgicheskoe lechenie posttravmaticheskoi arterial'noi neprokhodimosti.

Diagnosis and surgical treatment of ischemic complications of trauma of peripheral vessels are analyzed. Thirty-eight patients with disease of ligated vessel and 48 patients with posttraumatic occlusion of great vessels were examined. Both diseases are included in one group called "posttraumatic arterial occlusion" due to similarity of clinical manifestations. This disease is diagnosed in 15 - 40% patients after vascular trauma. Bypass surgeries is the methods of choice for treatment of complications of isolated vascular trauma. This kind of surgery was used in 33 patients. If there are additional injuries of nervous trunks and tendons, direct autovenous revascularization is indicated. One-stage correction of injured vessels and adjacent structures was performed in 49.7% cases. The best results were achieved after bypass surgeries. The most number of unsatisfactory results were seen in patients with injuries of adjacent structures.

[Surgeries on major vessels in removal of different tumors]. / Operatsii na magistral'nykh sosudakh pri udalenii opukholei razlichnoi lokalizatsii.

Experience in diagnosis and surgical treatment of 49 patients with tumors of different localization close to their major with main vessels is analyzed. Two variants of tumor - vessel interrelation were seen, patients with iatrogenic vascular lesions were included into a separate group. In 9 patients (group 1) only extravasal compression by the tumor was seen. Most of these tumors were benign. In 15 patients (group 2) reconstructive vascular surgeries were performed because of close interrelation with the tumor or tumor spread into the vessel. Most of these tumors were malignant. Iatrogenic lesions of arteries during surgeries were in 25 patients (group 3). It is demonstrated that duplex sonography permits to diagnose affection of vessels by tumors without invasive procedures. All the patients underwent vascular reconstruction simultaneously with tumor removing. Sceletization of vessels with their decompression was the surgery of choice in benign tumors. In malignant tumors it is recommended to remove the tumor with affected segment of vessel and repair of blood flow. Ligation of vessel may be justified in some cases.

[The place of vascular surgery in the treatment of cancer patients]. / Mesto sosudistoi khirurgii v lechenii onkologicheskikh bol'nykh.

The aim of the present work was to analyze the reported data related to the diagnostic potential of delineating the degree of blood vessel involvement into the tumorous process in patients with cancer diseases of varying sites and to the choice of the method for surgical treatment of this group patients. Half century ago an idea was advanced of the necessity of performing vascular operations during evacuation of tumors of certain sites. Based on the analysis of numerous publications the authors have established that the lowering of the lethality and improvement of the quality of life in patients with oncopathology are determined in many respects by one-stage operations performed on the great vessels, allowing to broaden the indications for tumor resection. The review elucidates the current achievements of vascular surgery linked with oncology, mirrors the historical viewpoint of the given problem, describes an experience of different authors gained with the use of the modern noninvasive research modalities in the diagnosis of vascular involvement into tumorous growth. As dependent on the site, tumor morphology and hemodynamic significance of the affected vascular segment, the indications have been worked out for different types of operations on the arteries and veins. The authors emphasize the potential and safety of great vessel ligation after radical resection of tumors of certain sites.

Surgical strategy for combined wounds of vessels and internal organs.

Surgical strategy and outcomes were analysed for 51 patients with combined wounds of internal organs and major blood vessels, with total 87 organ and 65 vessel injures. In 29 cases intracavity vessels were injured, in 22 - peripheral ones. In 47 cases (92.1%) traumas were gunshot. On admission 43 patients were in poor clinical condition with III-IV grade shock. The delay of surgical intervention did not exceed 30-40 min, all patients were operated in emergency, regardless of complete preoperative preparation. Blood reinfusion was used for all intracavity bleedings. The consequence of surgical steps was determined by localization of vascular trauma, bleeding intensity and severity of organ injuries. In order to decrease invasiveness and duration of surgery, conventional wound suturing was used for 53 organs, vascular plasty and sutures - in 35 cases, ligation of vessels - in 27. Lobectomy was executed in 1 case, intestinal resection and anastomosis - in 8, ileo-and colostomy - in 7 patients. Total 73 internal organs and 62 vessels were reconstructed. Postoperative complications have developed in 30 patients (58.8%), lethal outcome occurred in 3 patients during operation and in 10 (25.4%) - postoperatively. The majority of complications and deaths were observed for thoracoabdominal traumas. High postoperative mortality was also seen for patients with combined injuries of abdominal organs and vessels (13.7%).