[Treatment of atherosclerotic lesion of the first segment of subclavian artery]. / Lechenie ateroskleroticheskogo porazheniya pervogo segmenta podklyuchichnoi arterii.

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

[Use of an ex vivo technique in a patient with renal arteriovenous malformation in complication endovascular treatment]. / Ispol'zovanie tekhniki ex vivo u patsienta s arteriovenoznoi mal'formatsiei pochek pri oslozhnenii éndovaskuliarnogo lecheniia.

Renal arteriovenous malformation is a rarely encountered disease characterized by the presence of a direct arteriovenous shunt between the renal artery and vein. This nosology was first described by Varela in 1928, and by 1997 the number of such cases amounted to slightly more than 200. Endovascular closure of a fistula seems to be an attractive method of treatment in view of low traumaticity and a short period of rehabilitation. However, as shown by our case report, this type of intervention in large-diameter fistulas may be associated with the development of life-threatening complications. In case of rupture of the renal capsule and/or arteriovenous aneurysm, radical nephrectomy, unfortunately, remains to be a method of choice. Described below is a case concerning treatment of a female patient presenting with bilateral arteriovenous malformations and the world's first emergency operation for a ruptured intraparenchymatous arteriovenous aneurysm using an extracorporeal technique.

[Diagnostic significance of the color duplex scanning in estimation of the arteries state at different stages of infrainguinal reconstructions]. / Diagnosticheskoe znachenie tsvetovogo dupleksnogo skanirovaniia v otsenke sostoianiia arterii na étapakh infraingvinal'nykh rekonstruktsii.

AIM: The study was aimed at assessing diagnostic possibilities of duplex scanning (DS) of lower limb arteries, used as 'ultrasonographic angiography' in patients presenting with critical ischaemia for appropriately planning complicated infrainguinal reconstructions at stages of surgical management, including dynamic follow up in the postoperative period. PATIENTS AND METHODS: We examined a total of 30 patients. Of these, 14 patients composed the control group and 16 patients with critical ischaemia of lower limb arteries who underwent 8 external iliac-tibial and 8 femorotibial bypass graftings with a relieving arteriovenous fistula and application of a venous cuff according to the type of 'St. Mary's boot'. All the 16 patients preoperatively underwent DS of lower limb arteries and CT angiography, as well as postoperative DS of the vessels of the zone of the operative intervention. We compared the possibilities of DS and CT angiography in the assessment of the state of various segments of lower limb arteries. The obtained findings were compared with the data of the 'golden standard' - X-ray contrast enhanced angiography or intraoperative revision. RESULTS: In assessing the state of the aortoiliac segment, sensitivity and specificity of the both methods amounted to 100%. In assessing patency of the femoropopliteal segment, sensitivity and specificity of DS amounted to 93.7 and 100%, with those for CT angiography equalling 87.5 and 100%. Assessing patency of arteries of the crus, sensitivity and specificity of the both methods amounted to 87.5 and 93.7%, respectively. In the postoperative period it was revealed that a prognostically favourable factor for shunt functioning is the value of the volumetric velocity of blood flow in the shunt at the level of the middle third of the femur, equalling the sum of volumetric velocities of blood flow in the donor artery distal to and in the relieving vein proximal to the anastomosis. Important prognostic parameters of shunt functioning were also the values of linear velocity of blood flow both in the shunt and donor artery. CONCLUSION: Strict compliance with the methodology and protocol of DS makes it possible to evaluate the condition of outflow pathways while planning the intervention, to assess functioning of the shunt in the postoperative period and to work out criteria for favourable functioning of the infrainguinal shunt for regular dynamic control over the state of the revascularized limb.

[Protocol of preventing perioperative strokes in reconstructions of carotid artery bifurcation].

Presented herein is a protocol of preventing perioperative strokes in reconstructions of bifurcation of the carotid artery, used at the Department of Vascular Surgery of the Institute of Surgery named after A.V. Vishnevsky. The authors analysed the results of 630 primary carotid endarterectomies performed for atherosclerosis under general anaesthesia over the period from 2008 to 2010. Tolerance of the brain to carotid clamping was determined by measuring cerebral retrograde arterial pressure. Of the 630 operations, 65 (10.3%) interventions were carried out under temporal internal bypass. It was shown that the incidence rate of perioperative neurological complications among those tolerating carotid artery clamping was slightly lower than in the non-tolerating patients, with the incidence rate of strokes amounting to 1.8 and 3.1%, and that of "stroke + stroke-related mortality" amounting to 2.1 and 3.1%, respectively, but the differences were not statistically significant (p>0.5). Perioperative strokes in the absence of thrombosis of the reconstruction zone were observed in 0.6% of cases.

[Does the method of carotid reconstruction influence the outcomes of the intervention?].

AIM: to carry out comparative assessment of the immediate outcomes of eversion carotid endarterectomy, classical carotid endarterectomy and prosthetic repair of the internal carotid artery in atherosclerotic-genesis stenoses thereof. MATERIAL AND METHODS: the study was based on a retrospective analysis of the immediate results of 630 isolated primary open interventions on the bifurcation of the common carotid artery in atherosclerosis, performed at the Department of Vascular Surgery of the A.V. Vishnevsky Institute of Surgery over the period from January 2008 to December 2010. The choice of the method of intervention was based on the indications developed worked out at our Department with due regard for the clinical and morphological peculiarities of the lesion of the carotid bifurcation. RESULTS: the incidence of performing eversion carotid endarterectomy (416; 66%) in the entire group was significantly higher than that of classical carotid endarterectomy (127; 20%) and that of prosthetic repair of the internal carotid artery (87; 14%) (p=0.000). Thrombosis of the reconstructed internal carotid artery developed significantly more often (p<0.05) after prosthetic repair (4.6%) and classical carotid endarterectomy (3.9%) as compared with the eversion technique (0.7%). Frequency of the development of homolateral stroke after prosthetic repair of the internal carotid artery (4.6%) was higher than after eversion carotid endarterectomy (1.2%) and classical carotid endarterectomy (2.36%), however, these differences were statistically significant only when compared with the group of the eversion technique (p=0.000). All techniques were accompanied by low mortality from stroke (the eversion technique - 0.24%, classical carotid endarterectomy (0%), prosthetic repair of the internal carotid artery - 1.15%), and the groups did not differ significantly by this parameter (p>0.05). CONCLUSION: the choice of the method of carotid endarterectomy should be determined by the character of lesions of the carotid bifurcation, anatomical interrelationships in the operation wound, and tolerance of the brain to clamping of carotid arteries. Eversion carotid endarterectomy, once possible to perform, is the most preferable method of reconstruction in atherosclerotic lesions of the carotid bifurcation.

Remote results of reconstructive operations in pathological deformity of the internal carotid artery.

OBJECTIVE: to study remote results of surgical treatment of patients presenting with a pathological deformity of the internal carotid artery. METHODS: the study was based on retrospectively analysing the findings of examination and the outcomes of surgical treatment of 142 patients presenting with an isolated pathological deformity of the internal carotid artery (ICA), who underwent a total of 166 reconstructive operations. RESULTS: 7% of patients were operated on at the asymptomatic stage, more than half (56%) of the patients were found to have transient (21%) or persistent neurological deficit (35%), 37% of patients had stage III cerebrovascular insufficiency. Twenty-five (15%) operations were performed for C- and S-shape tortuosity, ninety-seven (58%) procedures for kinking of the internal carotid artery, and forty-four (27%) interventions for coiling. The operation of choice was resection with redressation of the internal carotid artery and reimplantation into the old ostium (74%). Analysing the results of surgical treatment showed its high neurological efficiency in prevention of cerebral circulation impairments (93% of patients at terms up to 25 years had no such complications), as well as clinical efficacy (relief of cerebrovascular insufficiency symptoms in 91.1% of patients). The effect obtained appeared to preserve during 2 and 5 years in 96% and 92% of patients, respectively, and at terms up to 25 years in 83%. The 3-, 5- and up- to-25-year survival amounted to 95%, 92% and 75%, respectively. Restenosis of the internal carotid artery was significantly more often observed after prosthetic repair of the artery (p <0.05) as compared with other methods of reconstruction employed. Thromboses of the internal carotid artery were encountered with similar frequency (8%) only after prosthetic repair and resection of the internal carotid artery with an «end-to-end¼ anastomosis, which was significantly more often than in resection with redressation (p <0.05). Stroke incidence in the remote postoperative period amounted to 0.8% and the «stroke + stroke-related mortality¼ parameter equalled 1.6%. CONCLUSION: the remote results of surgical treatment for pathological deformity of the internal carotid artery are strongly suggestive of high efficacy of this method of prevention of impairments of cerebral circulation and treatment of cerebrovascular insufficiency in patients with the pathology concerned. The operation of choice in pathological deformity of the internal carotid artery is resection with redressation of the internal carotid artery and reimplantation into the original ostium.

Clinical manifestations and diagnosis of pathological deformity of the internal carotid artery.

OBJECTIVE: to study clinical and morphological aspects of pathologically deformed pathological deformity of the internal carotid artery. METHODS: the study was based on retrospectively analysing the findings of examination and the outcomes of surgical treatment of 142 patients presenting with an isolated pathological deformity of the internal carotid artery (1СA), who underwent a total of 166 reconstructive operations. RESULTS: more than half (58%) of the patients were operated on for 1С A kinking, 27% for coiling and only 15% were found to have C- and S-shape tortuosity. The patients were predominantly women, with a male-to-female ratio of 1:1.6 (Р<0.01). The majority of the patients (61%) were operated on at the age varying from 51 to 70 years (P<0.01). Patients under 40 years appeared to more often (92%) suffer bilateral lesions (P<0.01). 56% of patients had a history of acute cerebral circulation impairment (P<0.05). A symptom-free course of the disease was more frequently encountered in unilateral lesions (P<0.01). Patients under 30 years were more often operated on at the pre-stroke stage of the disease (P<0.05). Patients with kinking of the internal carotid artery had a significantly higher risk (63%) of acute cerebral ischaemia (p<0.01). Arterial hypertension was revealed in 74% of patients. Incidence of acute cerebral ischaemia events was significantly higher in hypertensive patients (P<0.01). Pronounced haemodynamic impairments (bloodflow turbulence) were significantly more often (92%) detected in patients with kinking of the internal carotid artery (P<0.05). CONCLUSION: patients with clinical signs of cerebrovascular insufficiency, being relatively young and having concomitant arterial hypertension even with no objective signs of a stenotic lesion of coronary arteries should be referred to duplex scanning of brachiocephalic arteries in order to verify a pathological deformity of the internal carotid artery at the pre-stroke stage of the disease. An algorithm of examination including duplex scanning of brachiocephalic arteries and comprehensive magnetic resonance imaging made it possible to in short time obtain the in-depth information about the anatomical and topographical peculiarities of the pathological deformity of the internal carotid artery and to assess its haemodynamic significance, which in turn makes it possible to clearly and timely determine the treatment policy for the patient concerned.

[Immediate outcomes of reconstructive operations for pathological deformity of the internal carotid artery].

OBJECTIVE: To investigate the immediate outcomes of surgical treatment of patients presenting with pathological deformity of the internal carotid artery. METHODS: The study was based on retrospective analysis of the outcomes of surgical management of 142 patients with isolated pathological deformity of the internal carotid artery who underwent a total of 166 reconstructive procedures. RESULTS: Resection with redressing of the internal carotid artery and reimplantation into the old bed was a method of choice of repairing the deformed artery (74%). More often it was possible to have performed it in kinking, C- and S-shape tortuosity of the internal carotid artery, whereas prosthetic repair was more often in coiling (P < 0.05). A positive clinical effect of the operation was achieved in 97% of the patients. Neurological efficacy of the performed interventions depended upon the baseline degree of cerebrovascular insufficiency and the duration of clamping of carotid arteries (P < 0.05). The incidence of the development of thrombosis of the reconstructed internal carotid artery (1.2%) did not depend on either the form of pathological deformity or the method of reconstruction thereof. Cerebral circulation impairments in two (1.2%) cases were transitory and in three (1.8%) resulted in ischaemic stroke, one of which having become the cause of the patient's death. The index "stroke + lethality from stroke" amounted to 2.4%. Neurological complications had been caused by rheological impairments, instability of haemodynamics and inadequate redressing of the internal carotid artery. CONCLUSION: Analysing the immediate outcomes confirmed that surgical treatment of pathological deformity of the internal carotid artery is an effective method aimed at preventing cerebral circulation impairments and removal of cerebrovascular insufficiency in patients with the disease concerned.

[When should a pathological deformity of the internal carotid artery be operated on?].

The present study was aimed at optimizing the algorithm of examination and indications for operation in patients with a pathological deformity of the internal carotid artery. The work was based on a retrospective analysis of the therapeutic outcomes in 142 patients with an isolated pathological deformity of the internal carotid artery, who underwent a total of 166 reconstructive operations. Based on assessment of the diagnostic accuracy of the employed methods of diagnosis, we proposed an optimal algorithm of patient's examination including coloured duplex scanning and magnetic resonance angiography of the brachiocephalic arteries with simultaneous magnetic resonance tomography of the brain, followed by determining due indications for surgical treatment, depending on the baseline degree of cerebrovascular insufficiency and haemodynamiс significance of the pathological deformity of the internal carotid artery. The developed algorithm of examination makes it possible to timely and efficiently diagnose the disease and to determine due indications for surgical treatment of patients presenting with a pathological deformity of the internal carotid artery.