[Variant of endarterectomy from common carotid artery in its total occlusion]. / Variant éndarteréktomii iz obshchei sonnoi arterii pri ee total'noi okkliuzii.

Currently, there are relatively few publications in the literature on reconstruction of the common carotid artery (CCA). CCA occlusion occurs in 2-4% of patients examined for cerebrovascular disease. Most described surgical techniques of blood flow restoration for CCA occlusions are: coronary artery bypass grafting, retrograde loop endarterectomy, endovascular and hybrid interventions. These techniques yield good remote results, however they are not devoid of disadvantages. This article describes a clinical case report concerning successful autotransplantation of the CCA in a female patient presenting with a tandem lesion: total occlusion of the right CCA and haemodynamically significant stenosis of the ostium of the right internal carotid artery (ICA). This technique is considered to be an effective method of surgical treatment of lesions of the right CCA.

[Iliac artery reconstruction in patients with chronic critical limb ischemia: endarterectomy or replacement]. / Vybor metoda rekonstruktsii podvzdoshnykh arterii u bol'nykh khronicheskoi kriticheskoi ishemiei: endarterektomiya ili protezirovanie.

OBJECTIVE: To evaluate the effectiveness and postoperative morbidity after endarterectomy from the iliac arteries in comparison with ilio-femoral and aorto-femoral replacement in patients with chronic critical lower limb ischemia. MATERIAL AND METHODS: There were 95 patients with chronic critical lower limb ischemia. Iliac artery replacement was carried out in 43 (45.3%) patients, endarterectomy from the iliac arteries - in 52 (54.7%) cases. Trophic disorders on the lower extremities occurred in 36 (37.9%) patients. RESULTS: Iliac artery replacement was accompanied by postoperative wound suppuration and infection of prosthesis in 3 (6.9%) patients, postoperative ventral hernia in 2 (4.7%) patients. The total number of complications specific for endarterectomy (iliac artery perforation - 1 (1.9%) patient, iliac artery thrombosis - 3 (5.8%) patients) was similar to the literature data. Successful endarterectomy was performed in 52 (88.1%) patients. Iliac segment patency was similar in both groups throughout a 12-month follow-up period. CONCLUSION: Endarterectomy from the iliac arteries has some advantages over replacement and should be preferred for trophic complications on the lower extremities.

[Surgical treatment of a patient with false aneurysm of the ulnar artery]. / Khirurgicheskoe lechenie patsientki s lozhnoi anevrizmoi loktevoi arterii.

Today, the number of endovascular procedures is steadily growing. For example, there were 40.005 endovascular interventions in 2018. Most patients are discharged within 1-2 days after intervention due to its effectiveness and minimal invasiveness. However, physicians do not always note local postoperative complications. Multidisciplinary approach in follow-up and treatment of such patients is important. In particular, we talk about awareness of doctors of polyclinics about possible complications after arterial puncture. Effectiveness and favorable result of surgical treatment of local postoperative complications after arterial puncture are reported in the manuscript.

['Proper conduit' technique for chronic critical lower limb ischemia]. / Ispol'zovanie metodiki 'sobstvennogo konduita' pri lechenii patsienta s khronicheskoi kriticheskoi ishemiei nizhnei konechnosti.

The authors describe the technique of using autologous superficial femoral artery after endarterectomy for redo vascular surgery in case of unusable great saphenous vein.

[Use of the "Multitask" device while performing endarterectomy from iliac arteries]. / Ispol'zovanie instrumenta «Multitasc¼ pri vypolnenii endarterektomii iz podvzdoshnykh arterii.

AIM: The study was aimed at assessing efficacy of using the "MultiTASK" device manufactured by the Le Maitre Company while performing extended endarterectomy from iliac arteries in patients presenting with multilevel atherosclerotic lesions of the arterial bed and chronic ischaemia of lower extremities. PATIENTS AND METHODS: We analysed the outcomes of surgical management of a total of 37 patients presenting with multilevel atherosclerotic lesions of the common and external iliac arteries and arteries below the inguinal ligament over the period from 2012 to 2015 at the Department of Emergency Vascular Surgery of the Scientific Research Institute of Emergency Ambulance Care named after N.V. Sklifosovsky. Twenty one (56.8%) patients presented with haemodynamically significant stenoses of the iliac artery. Eleven (29.7%) patients had occlusion of the external iliac artery and five (13.5%) patients presented with occlusion of the common iliac artery in the distal portion. In all cases there was a second block, i. e. occlusion of the superficial femoral artery. RESULTS: The primary patency rate of the external iliac artery after endarterectomy amounted to 100%. Immediate complications directly associated with endarterectomy from the external iliac artery were encountered in one (2.7%) case - during back traction of the loop there occurred perforation of the wall of the external iliac artery by a calcified plaque, thus requiring external-iliac-common-femoral prosthetic repair. Amputation was performed in two (5.4%) patients (in both cases due to thrombosis and the development of ischaemic gangrene owing to poor condition of the distal arterial bed). One (2.7%) patient died of acute myocardial infarction. CONCLUSION: Extended endarterectomy by means of the "MultiTASC" device turned out efficient, yielding good immediate outcomes in atherosclerotic lesions of femoral arteries both as an independent operation and when combined with reconstruction of arteries beneath the inguinal ligament.

[Use of thrombolytic therapy and rheolytic thrombectomy in treatment of pulmonary artery thromboembolism].

The article deals with the results of combined treatment of patients with pulmonary thromboembolism by means of systemic thrombolytic therapy, anticoagulant therapy, and rheolytic thrombectomy during the period from 2012 to 2013. Thrombolytic therapy was used in 78 of 187 patients with the confirmed diagnosis of pulmonary thromboembolism (Group 1). The diagnosis was verified and therapeutic results were controlled by means of contrast-enhanced spiral computed tomography and perfusion scintigraphy. Thrombolysis was carried out using: tissue plasminogen activator - alteplase (61 cases) with administration of the full dose during 2 hours, streptokinase (14 cases) at a dose of 1.5 million IU in the mode of prolonged infusion during 24 hours and urokinase (3 cases) at a dose of 4400 IU/kg during 12 hours. 109 patients were subjected to anticoagulant therapy (Group 2). Five patients were subjected to rheolytic thrombectomy for desobstruction of the pulmonary artery. The method was used in patients with previously performed ineffective or partially effective thrombolytic therapy, as well as in patients with contraindications to thrombolysis. The lethality rate for TLT amounted to 5.4% and that for anticoagulant therapy 26.6%. Probability of a lethal outcome in Group 2 (anticoagulant therapy) turned out to be 6.71 times higher as compared with Group 1 (thrombolytic therapy). In all cases of using rheolytic thrombectomy we managed to achieve a decrease of the Miller index and systolic pressure in the pulmonary artery. Desobstruction of the pulmonary artery was complete in 3 cases. In two cases rheolytic thrombectomy was partially effective and the patients underwent repeat thrombolysis with a good clinical outcome. Using systemic thrombolysis in patients with pulmonary artery thromboembolism demonstrated a positive effect on the prognosis of survival. Rheolytic thrombectomy contributed to improvement of the results of thrombolytic therapy and may be used as an alternative method of treatment.

[A juxtarenal aneurysm: definition, classification, diagnosis and treatment].

An abdominal aortic aneurysm is one of the most severe manifestations of atherosclerosis, and their number has a steady tendency to increase. Due to the most complicated surgical technique, from infrarenal aneurysms a group of juxtarenal aneurysms was singled out. The presented herein review of the literature is a generalization of the currently existing data of foreign and Russian literature concerning the definition, classification, diagnosis and treatment of juxtarenal aneurysms of the abdominal aorta. Formulated and outlined herein are present-day approaches to treatment of juxtarenal aneurysms.

[Comparative characteristics of using isoflurane, sevoflurane and target concentration of propofol during reconstructive operations on the carotid arteries].

GOAL OF THE STUDY: To compare effects of isoflurane, sevoflurane and target concentration of propofol on the systemic hemodynamics, cerebral blood flow and cerebral oximetry of the brain during the carotid endarterectomy. MATERIALS AND METHODS: We studied 95 patients. The patients were divided into 3 groups. Group I included 26 patients who received isoflurane (under I MAC), Group II--40 patients who received sevoflurane (under I MAC), Group III--29 patients who received target concentration of propofol (under 4 mkg/ml) according to the method of Schneider Studied parameters were defined at the stages: before the operation (I), after the induction (II), after the intubation (III), during the separation of the carotid artery (IV), after the crossclamping of the carotid artery (V), before starting the bloodstream (VI), after starting of the bloodstream (VII), after the end of the operation (VIII). RESULTS: At the first stages of the operation, the using of isoflurane, sevoflurane and propofol was accompanied with moderate dose-dependent lowering of indicators ofcirculatory dynamics. The linear blood flow velocity (LBFV) in the middle cerebral artery on the affected side in the groups of isoflurane and propofol did not depend on the indicators ofcirculatory dynamics; in the sevoflurane group the correlation was traced During the breakoff of the blood circulation in the reconstructed carotid arteries while using the anesthesia of isoflurane, sevoflurane and propofol hemodynamics was stable. LBFV and cerebral oximetry (CO) in the groups of isoflurane and propofol did not depend on the systemic hemodynamics; in the sevoflurane group--they depended After the reinitiating of the bloodstream in the conditions of the isoflurane andpropofol anesthesia the reperfusion of the brain was moderate; in the conditions of the sevoflurane anesthesia the risk of reperfusion damage of the brain during the uncontrolled hypertension remained. At the stage of finishing the operation LBFV and CO did not depend on the systemic hemodynamics in the isoflurane and propofol groups, in the sevoflurane group the dependence was indicated. Consequently, at all the stages of the operation we indicated the disorder of the mechanisms of the brain blood supply autoregulation in the sevoflurane group.

[Comparison of morphological features of carotid arteries atherosclerotic plaques with clinical-instrumental data in symptomatic and asymptomatic patients with severe carotid atherosclerosis].

A complex histomorphometric and clinical-instrumental analysis of atherosclerotic lesions of the carotid arteries obtained during carotid endarterectomies (CEE) of patients with hemodynamically significant stenoses was conducted. Two groups of patients were compared: symptomatic, which earlier underwent cerebral vascular accident (CVA) or transitory ischemic attacks (TIA), and asymptomatic ones with no complications of the disease. Statistical analysis of clinical and laboratory data showed no significant differences between two groups except for the level of lipoprotein(a) [Lp(a)] in the blood plasma, which was higher (p<0.05) in asymptomatic patients compared with symptomatic ones. Statistical analysis of carotid arteries ultrasound duplex scanning (USDS) in the preoperative period did not reveal significant differences in the degree of maximum vessels stenosis between the compared groups of patients. Surface defects of atherosclerotic plaques (ASP) were shown to be significantly more common (p<0.05) in the group of symptomatic patients compared with asymptomatic ones. According to histological analysis 88% of extracted ASP was unstable in symptomatic patients and 77% of ASP - in asymptomatic patients. This may indicate high risk of CVA/TIA in both groups of patients. Statistical evaluation of magnetic resonance tomography (MRT) and USDS techniques in comparison with abilities of the most reliable histological analysis showed that both non-invasive diagnostic methods are highly sensitive in detecting unstable ASP, though MRT showed higher level of specificity compared with USDS.

[Administration of the generic prostaglandin E1 VAP 20® in patients with lower limb critical ischaemia: a prospective study].

OBJECTIVE: The study was aimed at assessing efficacy and safety of administering the generic alprostadil VAP in patients presenting with lower limb critical ischaemia. MATERIAL AND METHODS: We carried out a prospective study including a total of 30 patients with lower limb critical ischaemia. The patients' mean age was 67.7±7.8 years, with men predominating - 60%. Trophic ulcers were observed in 40% of patients. The proximal level of the lesion was localized in the arteries below the inguinal ligament in 19 (63.3%) patients, in the aortofemoral segment - in 9 (30%) patients, and in the popliteal-crural-plantar segment - in 2 (6.6%) subjects. The average ankle-brachial index amounted to 0.49±0.4. The studied agent was used at a dose of 40 mcg once a day in patients with stage III ischaemia and a dose of 40 mcg twice daily in patients with stage IV ischaemia. The drug was administered for 14 days followed by a 14-day follow-up period. RESULTS: The pain syndrome score over the 14 days of treatment decreased twofold from 6.1±2.5 to 3.5±2.6 and within the subsequent 14 days it did not increase - 2.4±3.1 (p< 0.05). The number of patients in whom the pain syndrome decreased by 50% amounted to 19 (63.3%). The consumption of analgesic agents decreased from 60% (at the beginning of treatment) to 12 (40%) (14 days after treatment) and to 8 (26.6%) (at the end of the follow-up period). In patients with trophic ulcers, the average size of the ulcers during treatment decreased from 3.3±3.7 cm to 2.8±3.8 after 14 days, and at the end of the follow-up period the size of the ulcers amounted to 2.1±2.8 cm (p >0.05). The number of patients responding to treatment amounted to 22 (77.3%). The ABI during treatment did not change, being 0.49 ± 0.4 at the beginning of treatment, 0.53±0.4 after 14 days of treatment, and 0.47±0.3 at the end of the follow-up period. There were no amputations either during treatment or within the follow-up period. Only one lethal outcome occurred which was related to acute coronary insufficiency. The "response to treatment" was significantly influenced only by the level of the proximal lesion and age (p<0.05). CONCLUSION: VAP 20® demonstrated good efficacy and tolerability comparable to those of the original preparations.

[The treatment of postinjection false aneurisms with arrosive bleeding of the magistral arteries in drug abuse patients].

The recent 10-15 years revealed such a disease in Russia as a false postinjection aneurism, complicated by the arrosive bleeding of the magistral arteries in drug abuse patients. It is a severe disease, by which the lethality and amputation rates are as high as 50%. The authors represent the experience of treatment of 30 patients. The goal of the study was to set the treatment algorythm of such patients. All the patients were operated on, the amputation was necessitated in 1 (3.3%) case.

[The oxidation stress, lipid metabolism and their relationship in patients with severe course of hypertension disease in aggregate with carotid stenosis].

The experimental samplings consisted of 25 patients with severe course of hypertension disease in aggregate with atherogenic carotid stenosis before and after carotid endarterectomy and 21 donors. The study was organized to analyze in lipid profile blood serum the content of malonic dialdehyde, ceruloplasmin, alpha-tocopherol, nitric oxide and angiotensin converting enzyme. The study established that in patients took place a reliably increased level of malonic dialdehyde, ceruloplasmin, alpha-tocopherol, nitric oxide and angiotensin converting enzyme. The patients with this pathology have a reliable positive correlation between the concentration of malonic dialdehydeand lipoproteids of very low density (r = 0.51), malonic dialdehyde and triglycerides (r = 0.36), malonic dialdehyde and cholesterol (r = 0.3). This data confirms the important role of peroxidation of lipids in the development of atherosclerosis. Therefore, the enhancement of oxidation stress and expressed dislipoproteidemia are established in patients with hypertension disease with carotids atherosclerosis as a background. This result testifies the pathogenic significance of these phenomena in the mechanisms of homeostasis disorders.

[Intraabdominal pressure alterations in ruptured abdominal aortic aneurysms].

The authors investigated the dependence of intraabdominal pressure on the volume of a retroperitoneal haematoma. The study included a total of thirty-four patients in whom elevation of intraabdominal pressure had solely been caused by haemorrhage into the retroperitoneal space. The volume of the retroperitoneal haematoma was calculated based on the findings of spiral computed tomography, whereas intraabdominal pressure was measured using the methods suggested by Sugrue M. and Kron I. L. The statistical analysis showed a moderate positive correlation between the retroperitoneal haematoma volume and the level of intraabdominal pressure. With the volume of the retroperitoneal haematoma approximating to 2,000 ml, intraperitoneal pressure was at the upper limit of the norm. Of the patients examined, none turned out to have developed the high intraperitoneal pressure syndrome.

[Determining surgical policy in combined atherosclerotic lesion of carotid arteries in patients with uncomplicated aortic aneurysm].

Presented herein are the outcomes of managing a total of twenty-six patients suffering from an uncomplicated abdominal aorta aneurysm with a concomitant atherosclerotic lesion of the coronary arteries, referred to our Clinic over the period form 2003 to 2006. Of these, nineteen (70%) patients were diagnosed with the first (symptom-free) stage of cerebral ischaemic disease, and six presented with the second stage [to have endured a transient ischaemic attack (TIA) within the terms from 16 to 3 months prior to admission]. Two patients had residual events of the previously sustained acute cerebral ischaemia (ACI) (stage 4). The current stage ofischaemic cerebral disease was determined according to the classification of A. V. Pokrovskii (1979). The haemodynamically significant stenoses of carotid arteries (over 70%) were revealed in five patients, an aneurysm of the internal carotid artery - in one patient, and eighteen patients were presenting with the degree of carotid arteries stenosis varying from 30 to 60% (of these, in two subjects after previously endured TIA, the plaque was heterogeneous and defined as embolism-threatening). No atherosclerotic lesions of the carotid artery were revealed in two patients, though these patients had previously sustained an AIA with the preserved neurological deficit by the moment of examination. Eight patients underwent reconstruction of the internal carotid arteries. The average age amounted to 64.5 years. Al of the eight operated on patients with a combination of ischaemic cerebral disease and an aneurysm of the abdominal aorta were found to have had no neurological complications either after the first, or after the second operations. The devised algorithm of examination and surgical management for patients presenting with an abdominal aorta aneurysm and a combined lesion of the brachiocephalic arteries made it possible to reduce the rate of neurological complication from 4.3% to 1.3%.

[Experience in treating embologenic thromboses of deep veins of lower extremities].

The present work deals with analysing the outcomes of surgical management carried out in a total of five hundred and sixty-six patients diagnosed as having embologenic thrombosis of the lower-limb deep veins. Of these, 377patients received a cava filter implanted, with the remaining 189 patients being subjected to thrombectomy from the iliac and femoral veins. In nineteen patients, the operation was supplemented by establishing an arteriovenous fistula. The decision of whether or not to perform a surgical intervention in patients presenting with thrombosis of deep veins of the lower extremities was made based on the type and pattern of the thrombus concerned. First of all, such surgery was indicated primarily for those diagnosed with a floating, embolus-hazardous thrombus. Thrombectomy was carried out in the patients with a favourable prognosis of the underlying disease, if activation of the pathological process was possible. Cava filters were implanted to the patients diagnosed as having a recurrent embolism, with an unfavourable prognosis of the course of the underlying disease, as well as to those presenting with a severe concomitant pathology. Ultrasonography-guided control is obligatory at all stages of management.

[Clinical and ultrasound diagnostics of acute venous thrombosis].

The results of clinical and ultrasound diagnostics of acute venous lower limbs thrombosis in 206 patients are analyzed. The patients were divided in two groups; those in the first group (n=96) had a diagnosed pulmonary embolism, patients of the second (n=110) had no signs of it. 37 (18%) patients had an asymptomatic course of venous thrombosis, 25 (68%) of those were diagnosed with pulmonary embolism. 154 (74%) patients had floating thrombs, which resulted in pulmonary embolism in 53%. Clinical and ultrasound criteria of embologenic venous trombosis are developed. It allows prognose the pulmonary embolism development and optimize the treatment tactics.

[Abdominal aorta ruptured aneurysm in patients with previously endured endovascular grafting for aortic aneurysm: clinical case reports].

The article deals with four reports of rarely encountered clinical cases, i. e., a ruptured aneurysm of the abdominal aorta in patients having previously sustained endovascular grafting of the abdominal aorta for the pathology concerned. The incidence rate of such complications we faced for the first time in 2001 has ever since amounted to 1.6 % of the total number of patients with a ruptured aneurysm admitted to our Department over the period form 2001 to 2006 (250 patients). All the patients were emergently operated on, with the lethality rate amounting to 50 % (two of the four patients died). The time having elapsed from the primary operation (endovascular grafting of the abdominal aorta aneurysm) till the rupture ranged from 11 days to 3 years.

[Radionuclide evaluation of the degree of tissue ischemia in acute thrombosis of the main arteries of the lower extremities].

The authors ascertained the value of three-phase scintigraphy using 99mTc pyrophotech (intravenously injected in a dose of 370-500 MBq, radiation exposure 2.1-2.85 mZv) in the diagnosis of disorders of great blood flow and soft tissue blood supply in patients with acute thrombosis of the main arteries, including acute thrombosis caused by injury. Examination of 68 patients with critical ischemia of the lower limbs identified 5 types of 99mTc pyrophotech incorporation into ischemic tissues in main artery thrombosis, embolism and atherosclerotic occlusions. The radionuclide technique in combination with ultrasonography and X-ray contrast angiography has shown it possible to choose adequate treatment policy and to specify the level of amputation and the scope of necrectomy when local muscle necrosis is developed.

[Radiation diagnosis of aortic aneurysmal ruptures with formation of anastomoses with the inferior cava and various organs].

The results of radiation diagnostic techniques were analyzed in 29 patients with aortic aneurysmal ruptures with formation of aortic anastomoses. The examination and treatment of 362 patients with abdominal aortic aneurysmal ruptures revealed that 23 (6.35%) patients had anastomoses (aortocaval (n = 15), aortoduodenal (n = 6), aortogastric (n = 1), and aortoureteral (n = 1)). Six patients were observed to have secondary aortointestinal anastomoses occurring after reconstructive vascular surgery. In one patient, abdominal aortic aneurysmal rupture first led to the formation of a primary aortoduodenal anastomosis and some time after surgery a secondary aortointestinal fistula emerged. One out of 113 patients with aortic dissecting aortic aneurysms had an aortopulmonary fistula. Ultrasonography, computed tomography, and angiography were performed in 27, 19, and 14 patients, respectively. Radiation diagnostic techniques revealed fistulas in 9 (31%) out of the 29 patients. The diagnosis of aortic anastomoses presents challenges.

[Flap transverse sternotomy during operations on the vessels and organs of the upper mediastinum and the first cervical zone].

A surgical approach to vessels and organs of the upper mediastinum was grounded, developed and tested. An experimental study of flap transverse sternotomy was carried out in 20 cadavers. A wide approach with throwing of the presternum was the best for manipulations in proximal parts of the aortic branches. This approach was also less traumatic.