[High efficacy of selective intra arterial thrombolysis in ischemic stroke patients with large-vessel occlusion].

Thrombolysis is the most effective treatment of acute ischemic stroke that increases the proportion of patients with good clinical outcome. Selective intra-arterial thrombolysis (IAT) can be used in a wider therapeutic window (up to 6-8 hours) under the angiographic control with tailoring of fibrinolytic dose. The results of IAT by a recombinant plasminogen activator in 2 patients are presented. Patient 1, male, 55 years old, with M1 cerebral middle artery (CMA) occlusion and with NIHSS score 13 on admission was treated by IAT after 7 hours of stroke onset. Recanalization was observed 40 minutes after IAT started. The NIHSS score was 8 after IAT. Patient 2, female, 64 y.o., with NIHSS score 20 on admission and C7 internal carotid artery and M1 CMA occlusion was treated by IAT. Recanalization was observed 60 minute after the beginning of IAT, with NIHSS score being decreased to 14. These clinical cases demonstrate the high efficacy of intra arterial thrombolysis in ischemic stroke patients.

Roentgenoendovascular treatment of Conn's syndrome.

This paper describes the first in the world experience with the treatment provided in 1990 to a female patient suffering from hypereldosteronism associated with adenoma of the left adrenal. The treatment consisted in endovascular destruction of the adrenal, which was performed by means of acute occlusion of the adrenal venous bed using a sclerosing agent. The intervention resulted in a decrease of arterial pressure (AP) from 240/140 to 130/80 mm Hg. The patient has been followed up for 13 years. No recurrence of the disease has been recorded. AP is within normal.

[Catheter balloon valvuloplasty: new possibilities in the surgical treatment of mitral stenosis]. / Kateternaia ballonnaia val'vuloplastika--novye vozmozhnosti v khirurgicheskom lechenii mitral'nogo stenoza.

A total of 170 catheter balloon valvuloplastic (CBV) operations for rheumatic mitral stenosis were carried out in patients aged 19 to 68, 30 of these in pregnant women, at A. V. Vishnevsky Institute of Surgery, Russian Academi of Medical Scients, from 1988 to 1994. Characteristic features of such operations are a minor surgical trauma and no necessity in deep narcosis and artificial circulation. Analysis of the immediate results and of the data of five-year follow-up brings the authors to a conclusion about the efficacy of the new method of treatment of this heart disease and about the physiological nature of forming an adequate route of blood flow into the right ventricle with a balloon. Comparing various balloon catheters for valvuloplasty and methods to carry out this procedure, the authors emphasize the advantages of the instruments and method developed by professor V. A. Silin et al. (St. Petersburg). The possibility of correction of mitral stenosis by CBV in pregnant women appears to be particularly important. Retrospective analysis of the immediate results and follow-up data helped the authors not only formulate the indications for this intervention, but permitted them to develop an original system of comprehensive clinical and instrumental assessment of the degree of involvement of the mitral valve and subvalvular structures, and of hemodynamic disorders.

[Radiographic endovascular correction of hyperaldosteronism in patients with arterial hypertension]. / Rentgenoéndovaskuliarnaia korrektsiia giperal'dosteronizma u bol'nykh arterial'noi gipertenziei.

The authors describe a new method of X-ray endovascular destruction of the adrenal in patients with arterial hypertension and hyperaldosteronism. Destruction of the adrenal is accomplished by acute occlusion of its venous channel by introduction of a 3% thrombovar solution through a catheter installed in the central vein of the suprarenal gland. This method was applied in 22 patients with arterial hypertension; essential hypertension with secondary hyperaldosteronism was found in 18 of them, renoparenchymatous hypertension in 2, aldosteroma of the left adrenal in one, and Itsenko-Cushing's disease in one patient. Acute occlusion of the adrenal venous channel was achieved in 20 patients. The intervention normalized blood pressure in 16 and reduced it significantly in 4 patients.

[Catheter balloon valvuloplasty in mitral stenosis (choice of surgical methods and evaluation of its results)]. / Kateternaia ballonnaia valvuloplastika pri mitralnom stenoze (vybor sposoba operatsii i klinicheskaia otsenka eë rezultatov).

Clinico-experimental study was undertaken for the choice of the optimal method for radiosurgical correction of the disease. Catheter balloon valvuloplasty (CBV), suggested by V. A. Silin and V. K. Sukhov with the use of balloon catheters of their design was found to be the most effective and safe method. This method was used to operate on 265 patients with mitral stenosis and various degree of affection of the valvular apparatus and complications in the form of calcinosis of the valve and cardiac fibrillation. Thirteen of the patients were operated on in pregnancy. CBV produced a positive therapeutic effect in more than 95% of patients. Increase of the mitral orifice area by 2.2-3.4 times was attended by a corresponding reduction of the diastolic pressure gradient at the mitral valve and systolic pressure in the pulmonary artery. The increase in the area of the mitral orifice and the positive changes of the hemodynamics values were more marked in patients with severe stenosis. The small number of complications (up to 9.5%) and the low lethality (up to 0.86%) allow the CBV method to be recommended as one of the main methods of surgical correction of mitral stenosis.

[Catheter-balloon valvuloplasty in mitral valve stenosis (selection of the method of procedure, immediate results and the criteria of patient selection]. / Kateternaia bollannaia val'vuloplastika pri mitral'nom stenoze (vybor sposoba operatsii, neposredstvennye rezul'taty, kriterii otbora bol'nykh.

Catheter-balloon valvuloplasty (CBV) was carried out in 80 patients with rheumatic mitral stenosis, whose ages ranged from 22 to 68 years. Seventeen of these patients were operated on for mitral valve restenosis; I-II degree calcinosis of the mitral valve was revealed in 18 patients; seven women underwent surgery in the 24th-32nd week of pregnancy. After applying various methods (19 cases) the authors used in the last series of operations (61 cases) the Silin-Sukhov method using an original dilatation catheter with a balloon measuring in diameter up to 34 mm, which allowed pressure of up to 8 atm. to be produced during a working cycle no longer than 8 sec. As the result of CBV, the area of the mitral orifice was enlarged by no less than twice in all patients, the pressure gradient through the mitral valve and systolic pressure in the pulmonary artery reduced. The total number of complications which called for operative treatment was 3.75%. CBV is a still developing method, but already today it may be considered the method of choice in the treatment of uncomplicated forms of mitral stenosis, in I-II degree calcinosis, and when the risk of the traditional surgical intervention on the heart is increased.

[Treatment of mitral valve stenosis in pregnant women by the method of balloon valvuloplasty]. / Lechenie mitral'nogo stenoza u beremennykh sposobom kateternoi ballonnoi val'vuloplastiki.

Catheter-balloon mitral valvuloplasty was performed in 7 females with rheumatic mitral stenosis on the 19th-32nd week of pregnancy. Four patients were operated on with signs of cardiac insufficiency, two--in a state of pulmonary pre-edema. Edema of the lungs in one patient continued developing on the operating table. The results of the treatment were good in all cases. The area of the mitral orifice increased from 0.9-1.75 to 2.4-3.5 cm2. The pressure gradient between the left atrium and the left ventricle dropped from 25-40 to 2-8 mm Hg. This was attended by the disappearance of the diastolic murmur and the clinical manifestations of stasis in pulmonary circulation in all patients. The development of mitral regurgitation after the operation was not encountered in any of the patients. The period of roentgenoscopy lasted 17.5 min. on the average. Screens were used to protect the fetus from the direct effect of the X-rays. Pregnancy ended in delivery in 6 patients; spontaneous labor at term occurred in 4, cesarean section had to be performed in one patient with placenta previa; one woman gave birth to twins on the 36th week of pregnancy. All the babies were healthy. Catheter-balloon valvulotomy does not yield to closed mitral commissurotomy in efficacy. The fact that it is only mildly injurious and does not need general anesthesia make this intervention preferable for pregnant women suffering from mitral stenosis.

[Complications of catheter-balloon valvuloplasty (analysis of their causes and the methods of prevention and treatment]. / Oslozhneniia kateternoi ballonnoi val'vuloplastiki (analiz prichin, sposoby profilaktiki i lecheniia).

The authors analyse the results of 1,404 operations of catheter-balloon valvuloplasty in stenoses of the pulmonary, aortic, and mitral valves. The experience was accumulated by the leading heart surgeons of the country from 1984 to 1990. The total number of complications was 77 (5.4%), 23 (1.6%) of them were fetal. The least number of complications (1.88%) occurred in catheter-balloon valvuloplasty in pulmonary stenosis, 1% were fetal. Complications in aortic stenosis were encountered in 11.3% of cases, 4.8% were fatal. The greatest number of complications (44) were recorded in mitral stenosis with a relatively low mortality (2.7%). The authors distinguish unspecific complications connected with the use of standard diagnostic catheters and instruments, and specific complications linked with the use of balloon catheters or caused by the course of the disease, and the character of the valve affection. As the result of analysis of the causes of complications, the authors suggest a system for preparation of patients for operation and the principles of its safe accomplishment and describe the order of the acts undertaken by the surgeon for the management of complications. Analysis of complications of catheter-balloon valvuloplasty demonstrates the efficacy and mild injurious character of this method, which makes it possible to rank it among the generally accepted cardiosurgical methods for the correction of heart valvular stenoses.

[Changes in intracardiac hemodynamics after percutaneous catheter balloon valvuloplasty in different types of valvular stenosis of the pulmonary artery]. / Izmeneniia vnuitriserdechnoi gemodinamiki posle chreskozhnoi kateternoi ballonnoi val'vuloplastiki razlichnykh tipov klapannogo stenoza legochnoi arterii.

Percutaneous catheter balloon valvuloplasty was carried out in 75 patients with valvular pulmonary stenosis (VPS), whose ages ranged from 18 months to 38 years. In 40 of them (53.3%) VPS was complicated by infundibular stenosis of the right ventricle. After percutaneous catheter balloon valvuloplasty 13 patients received out-patient treatment with beta-adrenergic blocking agents in doses of 20 to 120 mg/24 hours. Control examination in periods of 6 months to 2 years after the operation was conducted in 35 patients among whom 10 patients had been given beta-adrenergic blocking agents in the postoperative period. A stable reduction of the right ventricle-pulmonary artery (RV-PA) gradient and positive dynamics of the cardiac volume indices were recorded in 25 patients after correction of isolated VPS and in 6 patients after percutaneous catheter balloon valvuloplasty and treatment with beta-adrenergic blocking agents. The residual RV-PA gradient in 4 patients after treatment with beta-adrenergic blocking agents remained within a range of 30 mm Hg. Percutaneous catheter balloon valvuloplasty is an effective method for the correlation of isolated VPS. Coexistence of VPS with infundibular right-ventricular stenosis is not a contraindication for the use of this method for correcting the anomaly. In such a case the roentgenosurgical intervention should be supplemented by treatment with beta-adrenergic blocking agents in individual doses.

[Laser surgery in occlusive diseases of peripheral arteries]. / Lazernaia dezobliteratsiia perifericheskikh arterii pri okkliuziruiushchikh porazheniiakh.

The first experience with the use of an excimeric laser in the treatment of 24 patients with segmental occlusion of the peripheral arteries is discussed. It proved possible to recanalize the obstructed segment of the vessel for its whole distance in 13 patients. Analysis of the complications shows that further technological development of the method is necessary. Hemodynamic adequacy of restoration of the vascular lumen by laser recanalization in combination with balloon dilatation is demonstrated. Significant decrease of the risk of operative intervention, accelerated rehabilitation of patients, and an essential economical effect may be the advantages of the method.

[Myocardial asynergy of the left ventricle in patients with aortic stenosis]. / Asinergii miokarda levogo zheludochka u bo'lnykh s stenozom us'tia aorty.

Left ventriculograms obtained from 21 patients without any intracardiac hemodynamic abnormalities were analyzed by using the correlation method. The analysis revealed three functional areas of the left ventricle and defined normal values of their systolic and diastolic pulses. Hypo- and hyperkinesia of the functional areas in the left ventricle were quantitatively determined. Left ventricular cinematics was studied in 105 patients with aortic stenosis. Most patients of them were demonstrated regional cinematic abnormalities of various genesis. Local or total hypokinesia was detected in 62 per cent; hyperkinesia of its upper areas was found in a third; 7 per cent had normal dynamics of contraction in all the functional areas. It should be taken into account heterogeneous responses of the left ventricle to systolic overload while performing all investigations and studies or making clinical and prognostic assessments.

[Debatable problems of intravascular dilatation of the brachiocephalic artery]. / Diskussionnye voprosy éndovaskuliarnoi dilatatsii brakhiotsefal'nykharterii.

Roentgen--guided endovascular dilatation (RED) was conducted in 23 patients with atherosclerotic stenoses of branches of the arch of the aorta, in 20 with stenoses of the subclavian artery, and in 3 with stenoses of the brachiocephalic trunk. Before dilatation the patients had a systolic pressure gradient of 25 to 55 mm Hg in the region of the stenosis and constriction of the arterial lumen by 40 to 80%. Systolic pressure gradient disappeared completely in 17 cases and persisted at a level of 10 to 40 mm Hg in 7 cases. During RED of the left subclavian artery a complication, acute thrombosis of the distal part of the artery, occurred in one case. Indications for dilatation of stenosed subclavian arteries were elaborated on the basis of the accumulated experience.

[Evaluation of disorders of renal hemodynamics in Leriche's syndrome and vasorenal hypertension]. / Otsenka narushenii pochechnoi gemodinamiki pri sindrome lerisha i vazorenal'noi gipertenzii.

Combined assessment of changes in renal angio-architectonics and hemodynamics demonstrated significant disorders of those in cases of Leriche syndrome and vasorenal hypertension. These changes should not be neglected, if an adequate assessment of renal circulation and metabolism is to be made. It is in this way only that valid data on renal function can be obtained, an essential prerequisite for rational indications for the reconstruction of terminal abdominal aorta and renal arteries as well as the choice of an adequate scope and steps of intervention. In addition immediate and long-term prognosis of the course of the disease and the efficiency of intervention can thus be made.

[Elements of vascular surgery in surgery of the lungs and mediastinal organs]. / Elementy sosudistoi khirurgii pri operatsiiakh na legkikh i organakh sredosteniia.

The role of vascular components in the etiology and pathogenesis of some surgical diseases of the lungs and mediastinum is appraised. It is shown that elements of vascular surgery can be introduced into thoracic surgery as a result of which operations of the organ-preserving type can be undertaken.

[Surgical treatment procedures in patients with external and internal hepatobiliary fistulae]. / Taktika khirurgicheskogo lecheniia bol'nykh s naruzhnymi i vnutrennimi pechenochno-zhelchnymi svishchami.

Within a period of from 1967 to 1987, the authors treated 389 patients with injuries and diseases of the liver, bile ducts, adjacent organs, which were complicated by long-existing external and internal fistulas of the bile ducts, or intrahepatic cavities.

[Evaluation of the blood supply to the bronchial stump following resection of the lungs using a mechanical suture in the diagnosis and treatment of pulmonary hemorrhage]. / Otsenka krovosnabzheniia kul'ti bronkha posle rezektsii legkikh s ispol'zovaniem mekhanicheskogo shva v diagnostike i lechenii legochnykh krovotechenii.

The authors analysed angiograms of 34 patients who had been operated on the lungs with the use of mechanical suturing instruments to determine the effect of the mechanical suture (MS) of the bronchial stump on the development of hemoptysis and pulmonary hemorrhage. They studied the possibility of applying transcatheter endovascular occlusion (TEO) of the bronchial arteries (BA) in the management of hemoptysis of this etiology. In 70% of patients hyperplasia of the BA developed in the MS region in the late postoperative period; which was the source of pulmonary hemorrhage in 75% of cases. Among the patients, 19 were subjected to BA TEO for pulmonary hemorrhage. In 13 cases the bronchial stump with MS was the source of hemorrhage. Hemoptysis is a late complication of lung resection with the use of MS. Preference should be given to BA TEO in the management of this complication.

[Preoperative roentgeno-endovascular occlusion of the branches of the hepatic artery in focal lesions of the liver]. / Predoperatsionnaia rentgenoendovaskuliarnaia okkliuziia vetvei pechenochnoi arterii pri ochagovykh porazheniiakh pecheni.

Preoperative roentgenendovascular occlusion of branches of the hepatic artery was performed in 22 patients with local alterations of the liver. The occlusion was fulfilled with artificial emboli from hydrogel of a spherical and cylindrical form. Metallic spirals were additionally introduced into the artery lumen to 13 patients. All the patients were operated upon 1-10 days after REO (hemihepatectomy or subsegmentary resection of the liver). When using the method of REO the intraoperative blood loss was several times less, not more than 0.35 l.