[The value of optical coherence tomography and morphometry in evaluating the peripancreatic adipose tissue in infected pancreatic necrosis]. / Znachenie opticheskoi kogerentnoi tomografii i morfometrii dlia otsenki sostoianiia parapankreaticheskoi zhirovoi kletchatki pri infitsirovannom pankreonekroze.

OBJECTIVE: To investigate the morphometric and optical coherence tomography (OCT) characteristics of the microstructure of retroperitoneal peripancreatic adipose tissue during passive drainage and active perfusion-aspiration drainage for infected pancreatic necrosis. MATERIAL AND METHODS: The authors analyzed 74 samples of peripancreatic adipose tissue obtained from 37 patients with passive (Group 1) and active perfusion-aspiration drainage (Group 2) of a focus of peripancreatitis. The tissues were examined with OCT, then fixed in a formalin solution and underwent histological examination, including morphometric one. RESULTS: The examined groups showed qualitative and quantitative differences in the tissue microstructure. In Group 1 samples, the proportion (median (upper quartile; lower quartile)) of interlobular connective tissue was 5.6 (3.9; 6.1)%; and that of adipocytes was 44.6 (41.2; 51.6)%. Necrotic tissue occupied 46.2 (35.6; 56.1)% of the area of specimens. The OCT images of necrotic tissue displayed a preponderance of unstructured regions with a high signal level while the parenchymal areas showed a cellular structured pattern. In Group 2 samples, the proportion of interlobular connective tissue was 16.2 (11.4; 19.7)%, and that of adipocytes was 68.5 (59.7; 71.2)%. At the same time, Group 2 exhibited necrosis - 14.4 (11.5; 19.2%) that was 3.2 times less than in Group 1. The OCT images of Group 2 samples showed a preponderance of cellular structured regions characteristic of the parenchyma, with pronounced stromal elements, which corresponded to the histological pattern. CONCLUSION: Active perfusion-aspiration drainage of peripancreatic adipose tissue versus passive drainage is associated with a smaller proportion of necrotic tissue (14.4% versus 46.2%; p≤0.05) and a larger proportion of a stromal vascular component (16.2% vs. 5.6%; p≤0.05). OCT could qualitatively distinguish viable fat tissue parenchyma from necrotic areas, without specially preparing the samples, which was confirmed by histomorphometric results.

[On the classification of dissecting aortic aneurysms].

Aortic dissections are most commonly categorized into types A and B depending on the involvement of ascending or descending aorta based on the Stanford system and into types I, II and III using DeBakey classification. The latest classification was proposed by the European Society of Cardiology in 2001. The authors present their own classification of distal aortic dissecting aneurysms that takes into account antegrade and retrograde dissection of the aorta, besides localization of proximal fenestration. Surgical strategies for the treatment of different variants of aortic dissecting aneurysms are considered.

[A case of successful one-stage correction of abdominal aortic aneurysm and stenosis of the internal carotid artery in a 78-year-old patient]. / Sluchai uspeshnoi odnomementnoi korrektsii anevrizmy briushnoi aorty i stenoza vnutrennei sonnoi arterii u patsienta v vozraste 78 let.

Presented herein are the results of successful one-stage revascularization of the brain and reconstruction of the abdominal aorta in a 78-year old patient with infrarenal abdominal aortic aneurysm, the signs of rupture, stenosis of the left renal artery and multiple aortic arch lesions -- stenoses of both internal carotid arteries and both vertebral arteries. The sequence and technology of surgical intervention are described.

[Effect of aortic clamping on hemodynamics at reconstruction of the thoracoabdominal aorta]. / Vliianie perezhatiia aorty na gemodinamiku pri rekonstruktsii grudnoi i briushnoi aorty.

This paper describes an experience with monitoring and computerized follow up of the hemodynamic status in 60 patients at and right after reconstruction of the thoracoabdominal aorta. In addition to the routine control, measurements were made of the pressure in the large vessels and cavities of the heart, duration of each heart contraction and CI. The following parameters were computed automatically: the status of the ventricles for each heart contraction, resistance of the greater end pulmonary circulation, elasticity of the arterial, venous, pulmonary arterial and pulmonary venous reservoirs, also for each cardiac cycle. At the generally accepted monitoring the hemodynamic responses to the surgeon's manipulations on the aorta appear smoothed or are not visualized at all. The control of each heart contraction reveals the responses to application of the clamp and its removal from the aorta, with their hemodynamic significance being not questionable. Aortic clamping and clamp removal from the aorta are associated with the generalized response of the regulatory systems of the body. The slow and thoroughly controlled aortic clamping and graded, controlled blood flow restoration due to clamp removal as well as the use of sodium nitroprusside (trimetafan or isofluran are preferable) allow to avoid an abrupt stroke load of the left ventricle of the heart and, respectively, the generalized response of the regulatory systems of the body.

[Changes in renal and testicular veins in left-sided varicocele and choice of the surgical method in children and adolescents]. / Izmeneniia pochechnykh, iaichkovykh ven pri levostoronnem varikotsele i vybor metoda operatsii u detei i podrostkov.

Selective phleborenotesticulography, ++tensiometry of the left iliac, right and left renal veins, vena cava inferior, duplex scanning of the left renal vein were performed in 356, 296 and 57 patients, respectively, of a total of 356 examinees aged 8-17 years with left-side varicocele. Among other tests were measurements of hormones in the blood from the left and right testes (n = 24), pO2, pCO2. Stenosis, aortomesenteric compression (AMC) of the left renal vein, left-side venous renotesticular hypertension (RTH) of the left renal vein were diagnosed in 12, 342 and 158 patients, respectively. Secondary genesis of left varicocele has been proved. The diagnosis of left-side phlebohypertensive nephropathy was made preoperatively. Estradiol content in the blood of the left testis was 1.7 times higher than from the right one. 4 groups of patients were formed: group 1 patients (n = 142) had stenosis, AMC, dilatation of the testicular vein (DTV) and RTH; group 2 patients (n = 18) had AMC, DTV, borderline high pressure; group 3 patients (n = 18) had AMC, RTH, multiple thin testicular veins; group 4 patients (n = 174) had moderate AMC without hypertension. 160 patients of group 1 and 2 have undergone two-direction venous testiculo-iliac anastomosis operation. 193 patients of groups 3 and 4 have undergone Ivanissevich's operation. After Ivanissevich's operation 2 patients with secondary varicocele of the third degree retained varicocele of the first degree. After establishment of anastomoses, neither varicocele recurrences nor anastomosis thrombosis were registered.

[Aortic coarctation and the bicuspid aortic valve]. / Koarktatsiia aorty i dvustvorchatyi aortal'nyi klapan.

After the analysis of the long-term outcomes of aortic coarctation isolated resection the authors noted that many of the patients had valvular defects missed for diagnosis before the operation. ECG and X-ray of the heart established valvular defects in 37% of the operated patients. 61% of them had bicuspid valve associated in 80% of cases with pathologically dilated ascending aorta. Correlation-regression analysis showed the existence of a significant correlation between the width of the ascending aorta and age of the operated patient. This width in bicuspid valve patients was correlated with systolic and diastolic pressure, physical performance before surgery. Follow-up of patients after resection of aortic coarctation should be especially careful for patients with bicuspid aortic valve with dilatation of the ascending aorta and high arterial pressure.

[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.

[Clinical and ultrasonic validation for the intracavernous use of papaverin hydrochloride for the test screening of patients with arterial erectile impotence]. / Klinicheskoe i ul'trazvukovoe obosnovanie intrakavernoznogo primeneniia papaverina gidrokhlorida dlia skrining-testirovaniia bol'nykh s arterial'noi érektsionnoi impotentsiei.

Intracavernous administration of 2% papaverine hydrochloride solution, 4 ml, was conducted in 25 patients with various arterial erectile impotence and 25 patients with psychogenic impotence. The efficiency of the solution was judged from clinical findings and results of penile blood flow estimation via ultrasonic Doppler graphy 10 minutes after injection. Ultrasonic Doppler graphy involved calculation of the pulse wave acceleration measure and penile-brachial index of acceleration. In patients with psychogenic impotence the penile blood flow after intracavernous papaverine hydrochloride assumed the features of great blood flow, whereas it remained reduced in patients with arterial erectile impotence. In Doppler sonography, basic parameters were determined, viz assessment of the form of a Doppler wave, initial blood flow velocity, maximum blood flow velocity and their difference.

[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.

[Immunological disorders of homeostasis and the methods of their correction for the programmed and preoperative treatment of patients with nonspecific aorto-arteritis]. / Immunologicheskie narusheniia gomeostaza i metody ikh korrektsii dlia programmnogo i predoperatsionnogo lecheniia bol'nylh nespestsificheskim aorto-arteriitom.

The authors examined 29 patients with aorto-arteritis of unspecific origin of different duration and variants of affections of the major vessels. The patients were divided into groups with active and inactive course of the inflammatory process. The changes of immunological values and the phagocytosis data were more marked in the group with the active phase of the disease. These changes correlated with the data on unspecific inflammation and the clinical picture. Twenty-two patients were treated by hemosorption and immunocorrective measures. The fibrinogen concentration reduced, the ESR was normalized, and C-reactive protein became negative. The concentration of circulating immune complex and immunoglobulins diminished, the phagocytosis values became close to normal. It is concluded that hemosorption is an effective method of correction of immunological disorders in unspecific aorto-arteritis, both as an independent therapeutic method and as a measure of preoperative management.

[Arterial hypertension in the late period after the hemodynamically adequate correction of aortic coarctation]. / Arterial'naia gipertoniia v otdalennye sroki posle gemodinamicheski adekvatnoi korrektsii koarktatsii aorty.

The paper is concerned with a study of arterial hypertension in the long-term periods after the resection of coarctation of aorta in 77 patients aged 6 to 35 years. The complex of the patients' examination included bicycle ergometry. Arterial hypertension was revealed in 59.7% of the patients. In 83.2%, adequate correction was performed, in 16.8%, recoarctation was suspected. The rate of the development of hypertension in the operated under 16 years depends on the grade of the systolic AP increase before the operation. In those operated on in the older age, the rate of arterial hypertension depended on the time elapsed after the operation and the age by the moment of examination. In 50% of arterial hypertension patients, the work fitness corresponds to that in healthy subjects, in 28%, it constitutes 75% of the level seen in healthy subjects, and in 22%, it is low. Indications for operation in persons under 16 years rest on the grade of the arterial pressure increase; in the older age, indications are not dependent on the arterial pressure level.

[Methods of plastic surgery of the renal arteries in children with vasorenal hypertension]. / Metody plastiki pochechnykh arterii u detei s vazorenal'noi gipertenziei.

The work deals with the management of vasorenal hypertension in children and adolescents. The Bakulev Institute of Cardiovascular Surgery had 185 children with arterial hypertension from 1965 to 1990. Their ages ranged from 12 months to 17 years. The vasorenal genesis of hypertension was caused by fibromuscular dysplasia (FMD) of the renal arteries in 61 patients, unspecific aortoarteritis (UAA) in 39, hypoplasia of the abdominal aorta, kidneys, and renal arteries in 22 patients, supernumerary renal arteries were found in 7 patients. A total of 119 operations were carried out on 106 patients. Operations and one-stage revascularization of the kidneys and alimentary organs were performed on 22 patients, isolated reconstruction of the renal arteries on 51 patients. Among 99 patients with stenoses and aneurysms of the renal arteries 13 were treated by nephrectomy (11.3%). The postoperative mortality was 0.9%. A hypotensive effect was not produced in the immediate postoperative period in 5 patients with UAA (4.6%) and in one patient with, FMD (0.9%). Six operations were performed in late-term periods after the first operative interventions: 2 for aneurysm of autovenous grafts, 2 for restenosis of the renal arteries, and 2 for stenosis of the aorta distal to the primary site of reconstruction in UAA. Three patients died in the late-term periods. The stability of good operative results was highest in congenital hypoplasia of the aorta--100%. A favorable effect of the operation persists in 89.6% of patients with FMD of the renal arteries. The stability of the effect is lowest (75%) in UAA.

[Selective screening for abdominal aortic aneurysms by using the clinical examination and ultrasonic scanning]. / Selektivnyi skrining anevrizm briushnoi aorty s primeneniem klinicheskogo osmotra i ul'trazvukovogo skanirovaniia.

The results of screening for asymptomatic abdominal aortic aneurysms (AAA) in patients with great artery lesions and arterial hypertension (n = 163) are analyzed in the paper. Ten aneurysms were detected. These included 9 fusiform aneurysms, mean 43 +/- 3 mm in diameter and 1 ampullar one, 32 x 33 mm. The prevalence of abdominal aortic aneurysms was 7.2% in the risk group. It is concluded that palpation is of low informative value in the detection and differential diagnosis of asymptomatic abdominal aortic aneurysms of small diameter and in this respect ultrasonic scanning is of high informative value. It is concluded that the target-oriented screening for abdominal aortic aneurysms is essential and cost-effective in angiological patients, especially in concomitance of chronic lower extremity ischemia and arterial hypertension, as well as in patients with thoracic aortic aneurysms (except for posttraumatic ones).

[Simultaneous reconstructive operations in combined lesions of the coronary arteries, abdominal aorta and arteries of the lower extremities]. / Odnomomentnye rekonstruktivnye operatsii pri sochetannom porazhenii koronarnykh arterii, briushnoi aorty i sosudov nizhnikh konechnostei.

The work deals with the results of one-stage reconstructive surgical interventions in 15 patients with affection of the coronary arteries, abdominal aorta, and lower limb arteries. All patients underwent operation for the creation of an aortocoronary shunt in combination with various types of vascular reconstructive operations, including the formation of an ascending aorta -bifemoral shunt in 3 patients. The total hospital mortality was 26.7%. The authors discuss the indications and the surgical tactics of one-stage reconstructive interventions in combined affection of the coronary and peripheral arteries.

[Right aortic arch with a retro-esophageal diverticulum (embryology, anatomy, classification, clinical picture, diagnosis and surgical treatment)]. / Pravostoronniaia duga aorty s retroézofageal'nym divertikulom (émbriologiia, anatomiia, klassifikatsiia, klinika, diagnostika i khirurgicheskoe lechenie).

Five clinical cases (adult patients) are discussed in illustration of the problems of embryology, anatomy, clinical picture, and X-ray and angiographic diagnosis of a rare anomaly, right arch of the aorta (RAA) with retro-esophageal diverticulum of the aorta. According to I. J. Garti's classification, type C RAA was determined in 4 patients and type B RAA in one patient. The vascular ring around the esophagus and trachea was manifested clinically by mild respiratory disorders in 2 and marked dysphagia in all 5 patients, which required surgical correction. Four patients were operated on through a left posterolateral thoracotomy in the fourth-fifth intercostal space, one patient through a bilateral approach with division of the sternum on the level of the third intercostal space. The clinical effect of the operation was good in all patients. The indications for and the tactics of surgical treatment are discussed.

[Tactics of the surgical treatment of combined occlusive diseases of the coronary arteries, the abdominal aorta and the arteries of the lower extremities]. / Taktika khirurgicheskogo lecheniia sochetannykh okkliuziruiushchikh porazhenii koronarnykh arterii, briushnoi aorty i arterii nizhnikh konechnostei.

On the basis of experience in reconstructive operations on 250 patients with combined affection of the coronary arteries, abdominal aorta, and arteries of the lower limbs the authors discuss the diagnostic and tactical features of surgical management of these patients. The article dwells upon the necessary preoperative diagnostic algorithm as well as that in tactical variants of surgical treatment: (1) one-stage reconstructive operations on several vascular beds; (2) successive stage-by-stage treatment of patients with combined vascular pathology; (3) reconstructive vascular intervention on only one of the vascular beds. Correct practical solution of all these problems allowed the authors to reduce postoperative lethality to 5.4% among this grave contingent of patients with combined vascular pathology.

[New aspects of the surgical treatment of aortic coarctation]. / Nekotorye novye aspekty khirurgicheskogo lecheniia koarktatsii aorty.

The article substantiates the urgency of the problem and shows the results of surgical treatment of coarctation of the aorta in 103 patients who were operated on in the recent 5 years. The operation of choice was resection of the coarctation with the formation of an end-to-end anastomosis (90.3% of operations). Establishment of the anastomosis by methods developed at the department makes it possible to achieve good results and avoid complications in the immediate and late-term postoperative periods. An anomalous arterial branch, a reduced branch of the 5th aortic arch called Abbott's artery, was ligated in 40% of cases. No fatal outcomes occurred in the last 5 years in surgical treatment of coarctation of the aorta.

[Surgical treatment of nonspecific aorto-arteritis]. / Khirurgicheskoe lechenie nespetsificheskogo aorto-arterita.

The authors analyse experience with 273 operations carried out in 273 patients; 107 operations were conducted on the branches of the aortic arch, 136 were performed for the "middle aorta syndrome", and 30 operations were performed in affections of the terminal aorta and the iliac arteries. Experience is also shown in operative treatment of 32 patients with coexistent affections of the "middle aorta" and the branches of the aortic arch, the surgical tactics and the sequence of operations in this type of pathology are discussed. Problems dealing with the classification of nonspecific aorto-aortitis (NAA) are discussed, and the authors' classification of the variants of the vascular manifestations of the process is suggested. The authors draw attention to the need for preoperative management of patients with UAA for correcting the activity of the inflammatory process. Hemosorption and immunocorrective therapy are suggested for this purpose. Means for improving the results of surgical treatment of patients with UAA are suggested. The total mortality was 13%.

[Vascular ring: classification, clinical aspects, diagnosis and principles of surgical treatment]. / Sosudistoe kol'tso: klassifikatsiia, klinika, diagnostika i printsipy khirurgicheskogo lecheniia.

In the period between 1978 and 1989 operations were conducted on 56 patients with symptoms of the vascular ring (VR). The diagnosis of the disease was established on grounds of the clinical picture and the results of esophagography and angiocardiography. Double arch of the aorta (DAA) was recognized in 28 patients, anomalies of the right arch of the aorta (RAA) with VR formation in 25, and anomalies of the left arch of the aorta (LAA) in 3 patients. In 29 patients VR was combined with another congenital heart disease (CHD): with Fallot's tetralogy (FT) in 9 patients, with ventricular septal defect (VSD) in 4, and with coarctation of aorta (CA) in one patient. RAA anomalies were combined with FT in 6, with VSD in 4, and with CA in one patient. LAA anomalies were combined with VSD in 3 and with CA in one patient. VR separation was carried out through left anterior posterolateral thoracotomy in 91% of cases and through right thoracotomy in the remaining cases. In combination of VR with CHD the VR was corrected in one stage and then the CHD was corrected under extracorporeal circulation. Combination of RAA with FT allowed anastomosis with the use of a divided proximal stump of the left arch of the aorta to be established in 6 cases. In the group of 56 patients one died from hemorrhage during the operation. The late-term results are good.