[Results of comprehensive conservative treatment of patients with no-option chronic limb-threatening ischaemia]. / Rezul'taty kompleksnogo konservativnogo lecheniia 'nerekonstruktabel'nykh' patsientov s ugrozhaiushchei khronicheskoi ishemiei nizhnikh konechnostei.

AIM: The study was aimed at comparing efficacy of conventional conservative therapy and comprehensive treatment including a plasmid VEGF-165-gene therapy drug in 'no-option' chronic limb-threatening ischaemia with different prevalence of trophic ulcers and infection during a 1-year follow-up period. PATIENTS AND METHODS: A total of 101 patients (54% being men and 46% women, mean age 69 years) with 'no-option' chronic limb-threatening ischaemia underwent comprehensive conservative treatment. They were subdivided into 4 groups according to the WIFI classification: WIFI 130 (n=38), 131 (n=23), 230 (n=16), 231 (n=24). The control group patients (n=58) received standard treatment using a PGE1 analogue (Vasaprostan) and the study group patients (n=43) underwent standard conservative treatment (SCT) in combination with gene therapy. The end points of the study were as follows: major amputation rate, amputation-free survival, total mortality, and ulcer healing rate during a 1-year of follow up. RESULTS: Major amputation rate in the control and study groups amounted to 35 and 28% (p=0.48), respectively, with amputation-free survival of 53 and 63% (p=0.35), total mortality of 21 and 12% (p=0.23), ulcer healing rate of 31 and 51% (p=0.04), respectively. The WIfI classification made it possible to single out a subgroup of patients (WIfI combination 130) yielding other statistically significant results: major amputation rate 27% and 0% (p=0.03), amputation-free survival 59 and 94% (p=0.025), ulcer healing rate 50 and 88% (p=0.016), respectively. CONCLUSION: Using plasmid-based VEGF-165 gene therapy in the subgroup with the WIfI combination 130 decreases the major amputation rate (p=0.03), increases amputation-free survival (p=0.025) and promotes ulcer healing (p=0.016) compared with the standard therapy during 1-year follow up. No significant differences in the compared groups were revealed by all endpoints of the study for other combinations analysed. The total mortality rate in patients with limb-threatening ischaemia does not depend on either the initial severity of ulcer or the selcted methods of conservative treatment.

[Immediate results of conservative treatment of patients with unreconstructable critical limb ischaemia and trophic changes]. / Blizhaishie rezul'taty konservativnogo lecheniia 'nerekonstruktabel'nykh' bol'nykh s kriticheskoi ishemiei nizhnikh konechnostei s troficheskimi izmeneniiami.

The purpose of the study was to comparatively assess efficacy of using agents belonging to the group of prostaglandin E1 in comprehensive conservative treatment of patients with unreconstructable critical limb ischaemia and trophic changes by the frequency of major amputation, amputation-free survival, and total mortality by combinations of the WIfI classification during a 6-month follow up period. Our retrospective multicentre study enrolled a total of 109 patients, including 60 men and 49 women, with a mean age of 70±7.3 years. The patients were subdivided into 2 groups. Group 1 patients (n=58) received standard conservative therapy without prostaglandin E1 and group 2 patients (n=51) received similar treatment with the use of prostaglandin E1. The statistical analysis (chi-squared test, Fisher criterion, log-rank test) was carried out with regard to stratification of the patients in the groups by the WIfI component combinations. No statistically significant differences between the groups in the frequency of amputation and total mortality were revealed (p=0.094 and p=0.925, respectively). The use of the WIfI classification system made it possible to single out a cohort of patients (with a WIfI combination of 130) for whom the results of administering prostaglandin E1 statistically significantly differed by the frequency of amputation (p=0.042) and by amputation-free survival (p=0.017). No significant differences by these outcomes were obtained for other combinations analysed. A conclusion was drawn that using prostaglandin E1 in comprehensive conservative treatment decreased the frequency of amputation and increased amputation-free survival in patients presenting with unreconstructable critical limb ischaemia and referred to the category with a combination of 130 according to the WIfI classification.

[Differentiated approach to treatment of decompensated lower limb ischaemia with the use of the WIFI classification system]. / Differentsirovannyi podkhod k lecheniiu dekompensirovannoi ishemii nizhnikh konechnostei s ispol'zovaniem sistemnoi klassifikatsii WIfI.

In the present article, the authors substantiate the necessity of subdividing a heterogeneous cohort of patients presenting with Fontaine-Pokrovsky grade IV critical limb ischaemia into subgroups with the aim of making an appropriate therapeutic decision and predicting the outcome. We also translated into the Russian language the WIfI classification system developed by the Society for Vascular Surgery (2014) in order to predict limb loss and feasibility of performing revascularization. This is followed by comments on the classification, accompanied by examples of own clinical case studies. In order to check-up the ability of the SVS WIfI classification system to predict the one-year risk of major amputation in patients with decompensated ischaemia, we carried out a retrospective multicenter study, enrolling a total of 109 patients with unreconstructable stage IV chronic ischaemia. Our primary endpoint was the frequency of major amputation during the first year of follow up. The patients were divided into 4 subgroups based on a combination of the three WIfI domains, i. e., wound, ischaemia, and foot infection, respectively, as follows: 130 - 27% (n=29), 131 - 23% (n=25), 230 - 20% (n=22), and 231 - 30% (n=33). The frequency of amputation during the first year of follow-up with the natural course of the disease on the background of conventional therapy averagely amounted to 36%. By the WIfI component combinations, we revealed statistically significant differences between the subgroups (p=0.035): 130 - 21% (n=6), 131 - 28% (n=7), 230 - 36% (n=8), 231 - 55% (n=18). The WIfI classification makes it possible to predict the risk of major amputation in patients with limb-threatening ischaemia. The frequency of amputation during the first year of follow up in the natural course of the disease is associated not only with the WIfI clinical stage but also with the WIfI component combinations.

[REMOTE 3-YEAR RESULTS OF APPLICATION OF <> WAYS OF REVASCULARIZATION IN PATIENTS WITH CHRONIC ISCHEMIA OF LOWER EXTREMITIES].

There are several ways of <> revascularization such as revascularizated osteotrepanation of shinbone and lumbar sympathectomy (LS) for treatment of patients with chronic ischemia of lower extremities. They appeared to be sufficiently effective for the patients with II stage of the disease. Patients with critical ischemia (III stage) had persistent positive results after lumbar sympathectomy during 3-year period only in 33% of cases and using revacularized osteotrepnation - 46%. The difference in efficacy of treatment using LS and standard conservative therapy is statistically low significant, so that isn't allowed.recommending the sympathectomy for treatment of III stage ischemia. The method of revascularizated osteotrepanation of shinbone showed a reliably better result, therefore this way is reasonable to apply in surgery in case of III stage ischemia.

[Efficacy of using VEGF165 gene in comprehensive treatment of patients with stage 2A-3 lower limb chronic ischaemia].

The authors share their experience in treating a total of 100 patients presenting with stage 2A-3 chronic lower limb ischaemia according to the classification of Pokrovsky-Fontain (the clinical group was composed of 75 patients and the control group comprised 25 subjects), in whom it was impossible to perform surgical revascularization. The clinical group patients received in addition to the conventional vascular therapy local intramuscular injections of Neovasculogen (plasmid genetic construction containing human gene VEGF165) at a course dose of 2.4 mg. The results were assessed after 1 year. It was shown that administration of this gene therapeutic agent is safe with no local or systemic allergic reactions and free form neoplastic processes. Efficacy of treatment was assessed by registering the pain-free walking distance (PFWD), transcutaneous oxygen tension (TCPO2), linear velocity of blood flow, ankle-brachial index (ABI), angiography, and by means of SF-36 questionnaire. It was determined that after 12 months the statistical significance of intergroup and intragroup differences was reached for PFWD (increment 167.2%), TCPO2 (increment 20.4%). The highest clinical response for the PFWD was registered in patients with stage 3 of the disease (547.5%), as well as in those with multi-storey vascular lesions (269.1%). The obtained findings make it possible to consider gene therapy with Neovasculogen as an efficient component of comprehensive treatment of this cohort of patients.

[Therapeutic angiogenesis in treatment of patients with chronic obliterating diseases of lower limb arteries].

The authors share their experience gained in realization of the concept of "therapeutic angiogenesis" by means of the first Russian gene therapeutic agent Neovasculogen in comprehensive treatment of patients with stage II-III chronic obliterating disease of lower limb arteries (CODLLA) according to the Pokrovsky-Fontain classification. A total of 45 patients were treated. The findings were assessed and analyzed depending on the stage of chronic lower limb ischaemia. The clinical results including such measures such as the pain-free walk (PFW), ankle/brachial index (ABI), transcutaneously determined oxygen tension (TDOT), linear blood velocity (LBV) were followed up for 2 years. All patients were found to have good tolerance and at terms up to 2 years, and no side effect or complications were revealed. Patients with stage IIB of the disease after one year demonstrated statistically significant results suggesting improved blood circulation in the ischemized lower limbs after using the agent according to the indices of PFW, TDOT, LBV (p<0.05). In stage III of the disease? significant results were observed for PFD and TODT (p<0.05). Considerable part of patients with stage IIB and III CODDLLA (84.4%) showed increased physical capabilities for ambulation at the expense of considerably increased PFW (p<0.01). It was observed that using the agent was enough for obtaining a persistent satisfactory result preserving for not less than one year, with 50% of patients from stage IIB and 16.7% from stage III transferred to stage IIA of the disease. The effect of treatment persisted during the second year of follow up.

[The nearest and remote results in treatment aneurysms of the abdominal aorta and the main arteries].

In the modern literature are taken widely up questions of medical tactics at an aneurysm of abdominal aorta (AA) depending on its sizes, presence of signs and presence of risk factors. The purpose of work was studying current aneurysm illnesses in various arterial parts, developments of optimum tactics of conducting patients and its influence on the remote results of operative treatment. Into research have entered 51 patient, suffering aneurism of an aorta, it branches and other main arteries. The nearest and remote results of dynamic supervision and operative treatment have been studied. The age of patients was within the limits of from 50 till 88 years, and has on the average made 71,8 ± 6,16. A parity men and women 8:1. Diameter AA changed from 3 up to 12 sm. Aneurysms combination met in an ascending part of an aorta, subclavian arteries, brachiochephalic trunk, carotid, iliofemoral, popliteal and limb arteries. All patients had accompanying cardial pathology. Patients have been divided into 2 groups. The first was made by 34 patients by whom resection AA has been made. Patients of the second group (17 patients) has been executed by dynamic supervision. The remote results are studied at 32 (62,7%) persons. Term of supervision has made from 6 till 168 months on the average. Postoperative lethal cases at scheduled operations were 4,7%, the general postoperative lethal cases were about - 11,7%. At the analysis of the remote results it is established, that the survival rate in a year has made 100 %, 5 years - 83,3% of patients. Average life expectancy in the given group of patients has made 76,4 ± 4 years, that there corresponds to data the WOHC for a healthy population. Dynamic supervision in both groups has shown progressing current of aneurysms combination in all arterial parts. Our data show perspectivity of surgical treatment aneurysms of an aorta and the main arteries except for patients with multistorey aneurysmosis arteries of legs in a combination to the continued thrombosis, in which treatment we adhere conservative tactics.

[Specific medical strategy for aneurysm of the abdominal aorta].

An analysis of results of treatment of 323 patients with aneurysm of the abdominal and thoraco-abdominal parts of the aorta was made for the period from 1995 through 2010. The patients' age was within the limits from 45 to 88 years and was 67.2 +/- 6.5 at an average. In 65 (24.5%) patients the diagnosis of progressing type aneurysmatic disease of the aorta and other main arteries was made. At the department of surgery of vessels of the Yaroslavl regional clinical hospital (YRCH) planned operations were performed on 102 (31.6%) patients, by emergency indications--on 69 (21.3%), with the clinical picture of rupture on 25 (7.8%) patients. In addition, 58 (17.9%) patients were operated by emergency indications under conditions of the Central regional hospital (CRH). Dynamic follow-up was fulfilled in 69 (21.4%) cases. Results of the operative treatment in greater degree depended on the emergency of surgery and severity of the concomitant pathology. Common lethality after planned operations was 5.9%, emergent--20.3%, aneurysm rupture under conditions of CRH--91.4% of cases. Lethality in YRCH in emergent operations was considerably lower--52% of cases. Use of screening examinations in groups of risk beginning from 50 years of age and the population older than 60, active surgical strategy in small aneurysms, introduction of minimally traumatic operative approaches allow improvement of results of the treatment.

[Diagnosis and surgical treatment of ischemic lesions of the viscera in elderly patients with aorto-femoral atherosclerosis]. / Diagnostika i khirurgicheskoe lechenie ishemicheskikh porazhenii vistseral'nykh organov pri ateroskleroticheskom porazhenii aortobedrennogo segmenta u bol'nykh starshei vozrastnoi gruppy.

During the period from 1991 to 2000 161 patients with atherosclerosis of the aortic-femoral zone, aged over 60, underwent scheduled treatment in the vascular surgery department of the clinical regional hospital of the city of Yaroslavl. In 62 (38.5%) patients different pathology of the visceral arteries was revealed according to the diagnostic analysis. The chronic ischemic abdomen disease of the sub- and decompensated degree was revealed in 28 (45.2%) patients which had multiple lesions of the abdomen aorta visceral branches. 53 patients underwent different surgery. Postoperative hospital mortality rate was 9.4%. Good results were obtained in 79.2% of cases. There are many variants of reconstruction operative treatment of such disorders, but in patients aged over 70 the most appropriate one was the aortic-femoral reconstruction with a renewal of blood circulation in one, maximum two, affected visceral arteries. Today the priority is given to implantation of the beginning of arteria mesenterica inferior into the prosthesis and also to the aortic- or prosthesis-visceral autovein as grafting.

[Diagnosis and treatment of abdominal aortic aneurysm in elderly and older patients]. / Diagnostika i lechenie anevrizmy briushnoi aorty u bol'nykh pozhilogo i starcheskogo vozrasta.

83 patients over 60 years with abdominal aortic aneurysms (AAA) were treated from 1991 to 2000. 87.9% patients were men. Stable AAA were seen in 22 (26.5%) patients, 14 of them with small AAA were observed in terms from 1 month to 3 years. Three patients required surgery due to an increase of AAA size. Surgical treatment was performed in 83.1% patients, it was elective in 8 (11.6%), urgent--in 27 (39.1%), clinical picture of rupture was in 34 (49.3%) patients. There were no lethal outcomes in elective operations, lethality in urgent operations was 18.5%, in emergency--85.3%. Screening examinations in aged patients promote early diagnosis and improve results of treatment.

[Diagnosis and treatment of pseudoaneurysms after reconstructive interventions with the use of synthetic prostheses]. / Diagnostika i lechenie lozhnykh anevrizm posle rekonstruktivnykh vmeshatel'stv s ispol'zovaniem sinteticheskikh protezov

The author analyses an experience with treatment of 43 patients with false aneurysms of anastomoses after reconstructions in the aorto-femoral zone (5.8% of all the patients operated on). A combination with an infection of the prostheses was registered in 9 patients, two of them had aneurysms of the proximal aorto-prosthetic anastomosis. All the patients were operated upon. In three patients with aorto-prosthetic aneurysm resection of the proximal anastomosis was followed by reprosthesing and formation of a new aorto-prosthetic anastomosis. In combination with infection, the explants were completely ablated, the abdominal part of the aorta was ligated. The extraanatomical bifurcational axillary-femoral shunting was fulfilled with good results. When reconstructing the distal anastomoses the aneurysm was resected and the prosthesis was elongated with a linear insertion followed by the formation of a new distal anastomosis. The main blood flow in the extremity was obtained in all the patients. Lethality was 2.3%.