[The main approaches to reducing cardiovascular morbidity and mortality in Russia]. / Osnovnye napravleniya snizheniya zabolevayemosti i smertnosti ot serdechno-sosudistykh zabolevaniy v Rossii.

Analysis of medical statistical data and of the socioeconomic situation in the country brought the authors to a conclusion that at present the principal factors responsible for cardiovascular diseases, specifically, coronary disease and cerebrovascular disorders, are environmental factors, such as chronic stress, alcoholism and hard drinking, violation of social and hygienic norms of labor, and a number of factors related to medicine: no prophylactic check-ups and unavailability of effective drugs. "Internal risk factors" should not be disregarded as well: hypercholesterolemia, arterial hypertension, etc. Based on their results, the authors propose measures aimed at limitation of overall stress exposures, alcoholism and hard drinking control, sociohygienic labor protection, re-creation of a system of effective prophylactic check-ups, and making present-day effective drugs available for the population.

[An evaluation of the hemodynamic efficacy of an extra-intracranial microanastomosis in unilateral occlusion of the internal carotid artery]. / Otsenka gemodinamicheskoi éffektivnosti ékstra-intrakranial'nogo mikroanastomoza pri odnostoronnei okkliuzii vnutrennei sonnoi arterii.

The physicians of the A. N. Bakulev Institute for Cardiovascular Surgery examined 64 patients with unilateral atherosclerotic occlusion of the internal carotid artery (ICA). TCDG and angiography were employed before and after establishment of EICMA. TCDG proved highly informative in assessment of collateral circulation (sensitivity 95.6%). Indications to EICMA should be based on overall account of initial stage of cerebrovascular insufficiency and collateral circulation. EICMA is indicated for patients with compensated and relatively compensated cerebrovascular insufficiency (transient ischemic attacks, minor apoplexy, dyscirculatory encephalopathy), residue sequelae of ischemic apoplexy stroke, baseline poor collateral circulation. Differentiated approach to EICMA establishment allows improved outcomes of the surgery and revision of common among angio-neurosurgeons attitude to the above surgery in ICA occlusion.

[Indications for repairing the internal carotid artery after carotid endarterectomy]. / O pokazaniiakh k primeneniiu plastiki vnutrennei sonnoi arterii posle karotidnoi éndarteréktomii.

From 1983 to 1989, a total of 182 patients with atherosclerotic stenosis of the internal carotid artery (ICA) were examined and operated on. They underwent 198 carotid endarterectomies (EAE). In the long-term postoperative period, Doppler sonography and spectral analysis of an ultra Doppler signal were used to study 143 patients. Depending on the type of endarterectomy, 2 groups of patients were identified (1) 61 who had after EAE a plastic bifurcation operation with transition to the ostium of the ICA by means of a flap from a fragment of a synthetic prosthesis, autovein or xeno-pericardium; (2) 82 underwent EAE without dilatation of ICA. The analysis of the results of the studies revealed that after carotid EAE, the incidence of restenoses was 18.2%, that of thromboses was 8.4%, the incidence of atherosclerotic restenoses depended on the method to close the arteriotomic ostium: when the dilating flap was used, it was 1.5%, in isolated carotid EAE without its use, it was 11.03%. The incidence of myointimal restenoses in patients undergone plasty or no plasty of ICA was virtually equal. In atherosclerotic restenosis, 18.2% developed a negative dynamics of cerebrovascular insufficiency, whereas in thromboses 25% did, myointimal restenoses ran without clinical signs. The low incidence of atherosclerotic restenosis in plasty of carotid bifurcation made it the method of choice. Taking into account the nature of myointimal hyperplasia and the absence of clinical signs it should be noted that repeated reconstruction in this restenosis is not indicated, while in atherosclerotic restenosis, reconstruction is indicated in the presence of clinical manifestations.

[The epidemiology of occlusive lesions of the branches of the aortic arch]. / Epidemiologiia okkliuziruiushchikh porazhenii vetvei dugi aorty.

The most significant risk factors of the development of this pathology are: arterial hypertension, IHD, smoking. A group of patients younger than 50 was three times less that a group of patients 51-60 years old. Based on data of morbidity the authors counted the spread of occlusive lesions of the aorta arc branches in the population of men studied, which amounts 4.15%.

[The efficacy of the surgical treatment of occlusive lesions of the carotid arteries]. / Effektivnost' khirurgicheskogo lecheniia okkliuziruiushchikh porazhenii sonnykh arterii.

The authors from the A. N. Bakulev Institute of Cardiovascular Surgery analyze the results of surgical management of 154 males aged 40-60 years who suffered from carotid artery occlusions. The patients were divided into three groups of patients: (1) 28 patients with asymptomatic occlusions; (2) 36 with transient ischemic episodes (TIE), and (3) 90 with ischemic stroke. A set of techniques was used, which involved Doppler ultrasonography with spectral analysis of a Doppler ultrasonographic signal, study of regional brain blood flow from brain tissue 133Xe clearance by using the functional hypercapnic test, computed tomography and angiography. A total of 165 operations were performed. The outcomes of surgical management in the early postoperative period were studied in all patients. The long-term outcomes were analyzed in 130 patients who had been followed up for average 2.3 years. In the immediate postoperative period, the uncomplicated course was in 96.4% from Group 1, in 96.3% from Group 2, and in 94.4% from Group 3. Deaths occurred in 1.3%. In the late period, all patients from Group 1 had no signs of cerebrovascular insufficiency, an improvement was observed in 88.9 and 80.0% in Groups 2 and 3, respectively. No deaths occurred in all the groups in the late postoperative period. The paper discusses how the efficiency of surgical management is related to the cerebral hemodynamics and morphological changes in brain tissues in carotid artery occlusions.

[The causes of cerebral complications in patients with ischemic heart disease following myocardial revascularization operations]. / Prichiny tserebral'nykh oslozhnenii u bol'nykh ishemicheskoi bolezn'iu serdtsa posle operatsii revaskuliarizatsii miokarda.

In the period from Jan. 1988 to Jan. 1991 operations for the formation of an aortocoronary shunt were carried out in 437 patients at the Department of Combined Affections of the Coronary and Peripheral Arteries, Bakulev Research Institute. In some cases the operation was combined with resection of a postinfarction aneurysm of the left ventricle. Cerebral complications developed in the postoperative period in 28 (6.4%) patients. Their analysis showed the prevalence of severe forms of consciousness disturbances: coma and comatose states were encountered in 85.7% of cases. The main causes of the complications were acute heart failure (64.3%) and arterial embolism (14.3%). In only one case concomitant affection of the branches of the aortic arch was found to be the main cause of the development of a transitory ischemic attack. It is concluded that the development of acute heart failure in the patients may sharply increase the incidence of neurologic complications.

[The risk of neurological complications following aortocoronary bypass in patients with multifocal atherosclerosis]. / Risk nevrologicheskikh oslozhnenii posle aortokoronarnogo shuntirovaniia u bol'nykh s mul'tifokal'nym aterosklerozom.

Since January 1988 till June 1990 145 patients with combined coronary and vascular pathology have been operated on. Concomitant damage of aortic arch branches was observed in 54 patients (37.2%), and aortocoronary bypass surgery was performed in 40 patients without correction of the carotid vascular bed pathology. These patients comprised the basic group, which was divided into two subgroups depending on the clinical pattern of the disease: subgroup I--18 asymptomatic patients (45.0%), subgroup II--22 patients (55.0%) with clinical signs of the disease. The basic group comprised 257 patients with CHD alone and no damages of the aortic arch branches. In the postoperative period 10 out of 40 patients of the basic group developed neurological complications: brain hypoxia, delirious syndrome (3 patients); brain hypoxia, pre-comatose condition (3 patients); brain hypoxia, comatose condition (2 patients); transitory ischemic attack (2 patients). No significant differences in the development of complications have been observed in patients of both subgroups. In the control group neurological complications developed in 9 out of 257 patients (3.5%). The comparison of reasons responsible for the onset of complications in both groups has shown that acute heart failure was significantly predominant (10%) in the basic group, as compared to control group (1.9%). It has been concluded that after aortocoronary bypass surgery the risk of neurological complications was higher in patients with the accompanying damage of the aortic arch branches than in patients with CHD alone; the onset of acute heart failure in the early postoperative period increases the risk of neurological complications in such patients.

[Value of spectrum analysis of the ultrasonic Doppler signal in the diagnosis of occlusive diseases of the carotid arteries]. / Znachenie spektral'nogo analiza ul'trazvukovogo doplerovskogo signala v diagnostike okkliuziruiushchikh porazhenii sonnykh arterii.

Spectral analysis of the ultrasound Doppler's signal (SA UDS) was used to examine 216 patients with occlusive lesions of the carotid arteries followed by correlation of the data obtained to the carotid angiography data. Based on the doppler-angiographic correlations, diagnostic criteria for SA UDS were elaborated. It has been demonstrated that Amax is the most significant criterion, the increase of which by over 3.2 kHz points to the development of ICA stenosis. The magnitude of that characteristic exceeding 6.0 kHz indicates that ICA stenosis reaches more than 50%. The significance of SA UDS in ICA stenoses up to 50% amounted to 81.8%, in stenoses over 50%, it was 98.6%. In ICA occlusion the significance of the method was 99%.

[Tactics and indications for surgical treatment of patients with combined extra- and intracranial lesions of the carotid arteries]. / Taktika i pokazaniia k khirurgicheskomu lecheniiu bol'nykh s sochetannymi ékstra- i intrakranial'nymi porazheniiami sonnykh arterii.

The authors present the results of surgical treatment of patients with concomitant extra-intracranial and bilateral lesions of the carotid arteries. The patients underwent 163 operations for establishment of extra-intracranial microanastomosis (EICMA) including reconstruction of the extracranial segments with EICMA establishment (75 cases). In 66 cases, EICMA was performed for contralateral stenosis of the internal carotid artery (ICA). Of these, 22 patients later underwent carotid endarterectomy. In 14 patients, EICMA was established as the first stage before reconstruction of the iliofemoral segment. The operation was also performed in 8 patients with occlusion of the median cerebral artery or with the crimp of the carotid arteries. Examinations that included ultrasound dopplerography, transcranial dopplerography, studies of the cerebral blood flow according to 133Xe clearance and angiography were carried out. A study was made of the long-term results of the surgical treatment (from 0.5 to 5 years). It has been discovered that to estimate indications for surgical treatment, it is necessary that the data on the regional blood flow (RBF) be taken into account. In patients with stable cerebral hemodynamics according to the RBF that characterizes an uneventful course of ICA occlusion and in the decompensated type most typical of patients with pronounced postinsult neurological dificit, the establishment of EICMA is not indicated. Surgical treatment is most desirable in ICA occlusion (with preliminary reconstruction of the extracranial segments provided they are impaired) and in patients with unstable cerebral hemodynamics most typical of patients with transitory ischemic attacks, dyscirculatory encephalopathy, and minor brain stroke with chiefly mild residual phenomena of ischemic brain stroke.

[State of extracranial segments of the carotid arteries and primary open-angle glaucoma]. / Sostoianie ékstrakranial'nykh segmentov sonnykh arterii i pervichnaia otkrytougol'naia glaucoma.

Examinations of 203 patients (100 ones with occlusion abnormalities of the extracranial segments of the carotid arteries and 103 with primary open-angle glaucoma) by means of ophthalmologic and dopplerographic techniques have revealed no relationship between occlusion abnormalities of the carotid arteries and glaucoma development. This fact is explained by collateral circulation development via the orbital anastomosis and anterior connective artery that provide ocular circulation compensation in occlusion of the internal carotid artery. Noteworthy that the incidence of occlusion involvement of the carotid arteries in glaucoma (8.7 percent of cases) corresponds to the incidence of this abnormality in a random sample of an age-matched population. These results suggest an independent mechanism of circulation autoregulation in the eye and optic nerve.

[Tactics and indications in the surgical treatment of patients with combined extra- and intracranial lesions of the carotid arteries]. / Taktika i pokazaniia k khirurgicheskomu lecheniiu bol'nykh s sochetannymi ékstra-intrakranial'nymi porazheniiami sonnykh arterii.

The article deals with the results of surgical treatment of 159 patients with concomitant extra-intracranial and bilateral lesions of the carotid arteries; 163 operations were conducted for the formation of an extra-intracranial microanastomosis (EICMA) among which 75 operations comprised reconstruction of extracranial segments with creation of EICMA. In 66 cases EICMA was performed in contralateral stenosis of the internal carotid artery (in 22 with subsequent carotid endarterectomy), in 14 cases as the first stage before reconstruction of the iliofemoral segment, and in 8 cases in occlusion of the middle cerebral artery or in tortuous carotid arteries. Complex examination was conducted, including ultrasonic dopplerography, transcranial dopplerography, study of cerebral blood flow according to Xe-133 clearance, and angiography. The late-term results of surgery were studied in follow-up periods of 6 months to 5 years. It was found that to appraise the indications for surgical treatment it is necessary to take into account the data obtained in studying the regional cerebral blood flow. Surgical treatment is indicated in occlusion of the internal carotid artery (with preliminary reconstruction of extracranial segments when they are involved) in patients with unstable type of cerebral hemodynamics, which is most characteristic in patients with transitory ischemic episodes, dyscirculatory encephalopathy, small apoplexy and predominantly with mild sequelae of ischemic apoplexy.

[Regional cerebral blood flow and the collateral reserve of the blood supply to the brain in occlusion of the internal carotid artery]. / Regionarnyi mozgovoi krovotok i kollateral'nyi rezerv krovosnabzheniia golovonogo mozga pri okkliuzii vnutrennei sonnoi arterii.

Regional cerebral blood flow (rCBF) and CO2-reactivity were investigated by the clearance of inhalation 133Xe on a 32-detector system in 33 patients with occlusion of the internal carotid artery. The patients were divided into 2 groups: with few symptoms and residual effects of ischemic insult of various degrees of expression. rCBF asymmetry was more noticeable in the 2nd group than in the 1st group. Different types of reactions to hypercapnia were noted. Three types of cerebral hemodynamics (stable, unstable and decompensated) were singled out on the basis of a study of rCBF and CO2-reactivity results. It is more advisable that patients with an unstable type of hemodynamics should be operated on.

[Surgical treatment of combined extra- and intracranial lesions of the carotid arteries]. / Khirurgicheskoe lechnie sochetannykh ékstra- i intrakranial'nykh porazhenii sonnykh arterii.

The results of surgery for extra- and intracranial lesions of the carotid arteries in 108 patients are analysed. Application of non-invasive methods of examination parallelled with angiography provided a positive estimate of collateral circulation in unilateral occlusion of the internal carotid artery. Long-term postoperative studies showed best results in patients with transitory ischaemic attacks, minor stroke, dyscirculatory encephalopathy, and minor sequelae of ischaemic stroke. Surgery is contraindicated in moderate to severe poststroke neurological defect and does not have an advantage over conservative treatment.

[Neurologic manifestations of nonspecific aorto-arteritis of the branches of the aortic arch]. / Nevrologicheskie proiavleniia nespetsificheskogo aorto-arterita vetvei dugi aorty.

The authors have analyzed the results of clinico-angiographic examination of 123 patients with nonspecific aorto-arteritis of the branches of the aortic arch. It has been shown that occlusive damage is most frequently localized in the subclavicular arteries: more than half the patients presented damage to proximal segments of the carotid arteries. Involvement of distal segments of the carotid arteries is a very rare finding in this disease. In one-third of the patients the disease was combined with damage to the renal arteries. Most characteristic for nonspecific aorto-arteritis of the branches of the aortic arch is the brachiocerebral syndrome. A five-year follow-up revealed a progressive nature of cerebrovascular insufficiency. A correlation was established between the severity of neurologic manifestations and extension of the occlusive lesion. It was also noted that similar damage to the vessels may lead to most diverse variants of clinical manifestations.