[Multiple aortocoronary bypass without artificial circulation].

Results of 145 surgeries for direct myocardial revascularization without artificial circulation are presented. FC III and IV angina of effort was diagnosed in 80.6% and 13.5% of the patients respectively, acute coronary syndrome in 6.5%, past myocardial infarction in 63.8%. Mean left ventricular ejection fraction (EF) prior to surgery was 48.7 +/- 5.1%; it was below 40% in 28.8% of the patients. Three- and two-vessel coronary disease was documented in 54.7% and 35.3% of the patients respectively; 10% of them presented with the affected anterior interventricular branch, 14% with the stenotic trunk of the left coronary artery. Mean revascularization index increased from 22 to 76. The frequency of complete autoarterial revascularization amounted to 42.7%. Sequential and composite grafts were used in 93 and 257 cases respectively. No patient experienced perioperative myocardial infarction, acute disturbance of cerebral circulation, acute renal or cardiac insufficiency. Immediate postoperative hemorrhage requiring resternotomy developed in 0.9% of the patients, 1.2% with suppurative complications needed additional surgical treatment. It is concluded that myocardial revascularization on a beating heart is an efficacious and reliable method ensuring good results in the immediate and late postoperative period. Its success first and foremost depends on the previously gained experience that permits to operate patients with severe multi-vessel coronary artery disease and various concomitant disorders and thereby correct combined pathological conditions. The available data give reason to consider each patients in need of aortocoronary bypass as a candidate for myocardial revascularization on a beating heart regardless of the character and extent of coronary lesions and anatomical feature of the coronary bed.

[Functional rehabilitation of the myocardium after different kinds of direct revascularization of the myocardium in patients with occlusion lesion of the abdominal aorta and arteries of lower extremities].

The degree and terms of recovery of the functional state of the myocardium after direct revascularization of the myocardium under conditions of extracorporeal circulation and on the working heart were studied in 58 patients with occlusion lesion of the arteries of lower extremities. In 30 patients (1st group) coronary artery bypass grafting (CABG) was fulfilled under conditions of extracorporeal circulation, in 28 (2nd group) revascularization of the myocardium was fulfilled on the beating heart. In patients with occlusion lesion of the abdominal aorta and arteries of lower extremities and IHD of the III-IV functional class we followed the strategy of stage-by-stage interventions in the arterial basins. CABG is indicated at the first stage. The optimal method of direct revascularization of the myocardium was proved to be operation on the beating heart which had a number of advantages: lower risk of the development of postoperative complications, quicker restoration of the myocardium function and rehabilitation of the patients, shorter time for the 2nd stage of operation-revascularization of lower extremities.

[Tactics of surgical treatment of critical lower limbs ischemia and concomitant coronary heart disease class III-IV].

The possibility and use of prolonged epidural anesthesia in terms of preoperative care was studied in 78 patients. Patients with various stages of coronary arteries affection, central haemodynamics state and risk of reconstructive surgical treatment on lower limb arteries were marked out. Patient selection criteria for aortocoronary shunting or reconstructive operation on great lower limb vessels were worked out. It is proved, that prolonged epidural anesthesia allows not only to attain good analgesia but to minimize cardiac complications at reconstructive operations on abdominal aorta and its branches.

[Surgical treatment of patients with rupture of abdominal aorto-aneurysm].

Thr experience in surgical treatment of 69 patients with rupture of abdominal aorto-aneurysm was analyzed. Multifactorial statistical analysis was carried out to determine detect influence of different parameters on postoperative lethality. The most significant parameters were initial blood loss (odds ratio (OR) -- 10.4, confidence interval (CI) -- 2.0-37.1, intraoperative hemorrhage (OR=8.5, CI 1.5-27.8), minute diuresis (OR=15,7, CI 1.8- 49.3), location of rupture (OR=12.1, CI 2.0-33.5). Combination of two and more factors led to the most unfavorable prognosis. The proposed algorithm allowed the authors to optimize treatment policy and improve significantly results of surgical treatment of patients with rupture of abdominal aorto-aneurysm: postoperative lethality has decreased from 71.4 to 28.5%.

[Ruptures of abdominal aortic aneurysms. The clinical course and classification]. / Razryvy anevrizmy briushnoi aorty. Osobennosti klinicheskogo techeniia i klassifikatsiia.

Surgical treatment of abdominal aortic aneurysm (AAA) ruptures is a matter of great concern in current vascular surgery. The results of surgical treatment of patients presenting with such severe disease could have been improved due to the early and correct diagnosis. The present work is concerned with a study into the characteristic features and causes of the atypical clinical manifestations and the course of AAA ruptures as well as with the development of the classification accessible for practical uses. Later on it would allow to refine the treatment policy for an extremely severe patient group and to define a permissible algorithm of examination in the postoperative time and would favour the early diagnosis of disease. The study is based on an analysis of the clinical course of AAA rupture in 53 patients operated on at the Department of Vascular Surgery. MONIKI. The clinical manifestations were typical in 46 (86.8%) patients. The progressing course of AAA rupture was observed in 21 (39.6%) patients; the disease ran a wave-like course in 17 (32.1%) patients. Stabilization of the condition was marked in 15 (28.3%) cases. In 39 (73.6%) cases, AAA rupture affected the retro-peritoneal space, the free abdominal cavity was affected in 8 (15.1%), the duodenum in 2 (3.8%), the sigmoid intestine in 2 (3.8%), and the inferior vena cava in 2 (3.8%) of cases. The rupture of the posterior wall of the aortic aneurysm was identified in 29 (54.7%), of the lateral wall in 12 (22.6%), and of the anterior wall in 8 (15.1%) patients. Four (7.5%) patients demonstrated aneurysmal rupture of the iliac artery. The clinical manifestations of AAA rupture were marked by polymorphism whereas its course was often masked by other diseases making it difficult to establish the early and correct diagnosis. The difficulties in the diagnosis of AAA ruptures gave rise to a lot of diagnostic errors and late hospitalization to specialized unita.