[Optimal method of reconstruction in patients with pathology of the 1st segment of the subclavian artery]. / Optimal'nyi metod rekonstruktsii u patsientov s patologiei 1 segmenta podkliuchichnoi arterii.

The study enrolled a total of 318 patients presenting with lesions of the 1st segment of the subclavian artery and the clinical course of vertebrobasilar insufficiency. All patients prior to admission had been receiving the best course of medicamentous therapy under the supervision of a neurologist for more than 6 months but with no significant clinical improvement. According to the type of the reconstructive operation on the 1st segment of the subclavian artery, all patients were subdivided into three groups. Group I included 48 (15.1%) patients presenting with occlusion of the subclavian artery and undergoing carotid subclavian bypass grafting. Group II consisted of 224 (70.4%) patients who underwent endarterectomy from the subclavian artery and its transposition to the common carotid artery. Group III was composed of 46 (14.5%) patients presenting with local stenosis of the subclavian artery and subjected to stenting of the 1st segment of the subclavian artery. The main criteria for assessment of the results were patency of the zone of reconstruction and clinical improvement of the patient after surgery. RESULTS: Clinical improvement in the early postoperative period was observed in 301 (94%) patients. In Group I, in the early postoperative period, clinical improvement was achieved in 32 (66.7%) patients. Clinical improvement after 3 years persisted only in 16 (33.3%) patients. In Group II comprising patients with transposition of the subclavian artery to the common carotid artery, clinical improvement was observed in 223 (99.6%) patients. Within 3 years of follow-up, 13 (6.4%) patients were found to have a relapse of the clinical picture of vertebrobasilar insufficiency. Clinical improvement after transposition of the subclavian artery to the common carotid artery at 3 years persisted in 210 (93.6%) patients. In Group III patients after stenting of the 1st segment of the subclavian artery in the early postoperative period and during the follow-up period up to 1 year, the angiographic and clinical success amounted to 100%. After 3 years, 8 (17.3%) patients developed relapse of the clinical course because of restenosis, fracture, and thrombosis of the stent. Clinical improvement at 3 years persisted only in 38 (82.6%) patients after stenting. Comparing the remote results demonstrated that transposition of the subclavian artery to the common carotid artery turned out to be the most justified (p<0.05). CONCLUSION: For reconstruction of the 1st segment of the subclavian artery, an operation of choice is transposition of the subclavian artery to the common carotid artery.

[Surgical treatment of the patients with fibromuscular dysplasia of internal carotid arteries].

The results of surgical treatment of 78 patients with fibromuscular dysplasia (FMD) of internal carotid artery (ICA) were described in the article. FMD ICA was combined with atherosclerosis of carotid artery at 68 (87,2%) patients and with pathological kinking of ICA at 64 (82%) patients. We provide information about frequency of systemic inflammation response syndrome at FMD ICA, and necessity of its treatment for improvement of surgical outcomes in these patients. The access to extracranial portion of ICA was shown which is necessary for an adequate estimation of changes artery at fibromuscular dysplasia. The role of spastic component in development of characteristic changes at FMD ICA was proved. We propose the specific approach for choosing the method of reconstruction of ICA and definition of the indications to prosthetision at FMD.

[The role of beta-adrenoblockers and If-inhibitor ivabradine in lowering of rate of development of cardiac complications after carotid endarterectomy].

Aim of the study was to assess effect of therapy with b-adrenoblockers and If-inhibitors on the rate of development of coronary complications of carotid endarterectomy. Patients (n=111, mean age 61 +/- 4 years) subjected to carotid endarterectomy in 2006 - 2007 were divided into 3 groups according to therapy in pre-, intra-, and postoperative period. Group 1 consisted of 48 patients treated with metoprolol. Group 2 comprised 33 patients with contraindications to b-adrenoblockers who were treated with If-inhibitor ivabradine. Patients of control group 3 (n=30) received neither b-adrenoblocker nor If-inhibitor. There were no significant differences between groups in sex, age, concomitant pathology, and degree of stenosis of operated carotid artery. We assessed rate of development of ischemia and myocardial infarction during operation and in first 24 hours after surgery. In group 1 mean 24 hour heart rate according to Holter ECG monitoring after 7 days of therapy decreased by 14 +/- 3,7 beats/min, episodes of ischemia after surgery were registered in 4 patients (8%). In group 2 mean 24 hour heart rate decreased by 10 +/- 2,5 beats/min, 4 patients (12%) had signs of myocardial ischemia during first 24 hours after surgery. There were no myocardial infarctions in groups 1 and 2. In control group mean 24 hour heart rate did not significantly change. Significantly higher number of postoperative coronary complications was revealed among patients of this group: 2 (6%) developed myocardial infarctions, in 5 (17%) appeared signs of myocardial ischemia. Administration of b-adrenoblocker metoprolol and If-inhibitor ivabradine significantly lowers rate of development of coronary complications after carotid endarterectomy. Ivabradine is indicated to patients with contra indications to b-adrenoblockers.