[First case of thrombolysis with non-immunogenic staphylokinase in a patient with ischemic stroke receiving dabigatran etexilate followed by thrombectomy]. / Pervyi sluchai tromboliticheskoi terapii pri pomoshchi neimmunnogennoi stafilokinazy u patsientki s ishemicheskim insul'tom, poluchayushchei dabigatrana eteksilat, s posleduyushchei trombektomiei.

Currently, five oral anticoagulants have been shown to be effective in preventing recurrent ischemic stroke and/or systemic embolism in patients with non-valvular atrial fibrillation. However, 1.1-2.2% of patients taking oral anticoagulants develop ischemic strokes. The use of oral anticoagulants limits the possibility of systemic thrombolytic therapy, as this is associated with an increased risk of symptomatic hemorrhagic transformation. The exception is cases when, with the help of a specific antagonist, it is possible to neutralize the effect of the anticoagulant in the shortest possible time and achieve normocoagulation. Currently, the Russian Federation allows two drugs for systemic thrombolytic therapy in patients with ischemic stroke in the «therapeutic window¼ up to 4.5 hours from the onset of the disease - recombinant tissue plasminogen activator and non-immunogenic staphylokinase, which showed no less efficacy and safety in the FRIDA study compared to recombinant tissue plasminogen activator. This article describes a clinical case of the first systemic thrombolytic therapy with a non-immunogenic staphylokinase after the use of idarucizumab in a patient taking dabigatran etexilate, followed by thrombectomy.

Endovascular Occlusion of Giant Posttraumatic Pseudo-Aneurysm of Superior Mesenteric Artery Connected to Mesenteric Arteriovenous Fistula.

The aim of the study was to show the capabilities of endovascular occlusion of giant posttraumatic pseudo-aneurysm of superior mesenteric artery (SMA) connected to a mesenteric arteriovenous fistula (AVF) under the conditions of portal hypertension and life-threatening esophageal variceal bleeding. MATERIALS AND METHODS: A 27-old male patient underwent endovascular occlusion; the patient being hospitalized with a clinical picture of gastrointestinal bleeding. The examinations: ultrasound, esophagogastroduodenoscopy, multispiral computed tomography with angiography - revealed the source of bleeding to be esophageal varices against the background of portal hypertension caused by massive arteriovenous shunt, its source being AVF with an aneurysmal component (32×35 mm in size) between SMA and superior mesenteric vein (SMV) dilated up to 50 mm in diameter. Patient's past medical history recorded that 4.5 years ago the patient had undergone the resection of a small intestine area due to a penetrating stab wound in the abdominal cavity. Taking into consideration an extremely high operative intervention risk due to the condition severity related to blood loss, portal hypertension, and ascites, it was decided to embolize AVF with a vascular occluder - Amplatzer Vascular Plug II (USA), 14×10 mm in size. RESULTS: A unique endovascular intervention - transcatheter occlusion of pseudo-aneurysm and AVF separation - was performed in life-threatening esophageal variceal bleeding under the condition of a giant post-traumatic aneurysm of SMA and mesenteric AVF. Due to an extremely large-sized SMV and an arterial pseudo-aneurysm, first ever we used the technique applied for transcatheter occlusion of a cardiac septum defect.Occluder implantation enabled to completely close the communication of aneurysmatic AVF with SMV, and occlude the aneurysm cavity. During an immediate postoperative period portal hypertension was arrested. No recurrent bleedings occurred within 4 postoperative months.

[Treatment of acute tandem occlusion of arteries of anterior cerebral circulation without emergency stenting]. / Lechenie ostroi tandemnoi okkliuzii arterii perednei tsirkuliatsii golovnogo mozga bez ékstrennogo stentirovaniia.

The article deals with problems of endovascular treatment of acute tandem and isolated occlusions of arteries of the anterior cerebral circulation, as well as the problem of reocclusions and new occlusions of these target arteries in the early postoperative period after thrombectomy. PURPOSE: To determine the effect of reocclusions and new, previously not identified occlusions of the carotid artery and middle cerebral artery after cerebral thrombectomy on the outcomes of ischaemic stroke, as well as to substantiate feasibility of endovascular policy without simultaneous carotid stenting in thrombectomy in case of tandem occlusions of arteries of the anterior cerebral circulation. PATIENTS AND METHODS: We studied the results of endovascular treatment of 52 patients with acute ischaemic stroke, including 26 patients with combined occlusions of the internal carotid and middle cerebral arteries (group 1) and 26 patients with isolated occlusion of the M1 segment of the middle cerebral artery or its equivalent (group 2). The groups were compared using the Chi-squared and Mann-Whitney test, and the effect of the factors was assessed by calculating the relative risk. RESULTS: Disability of patients in group 1 was significantly two-fold higher as compared with group 2. Differences in mortality and frequency of a good functional outcome (0-2 points on the Rankin scale) were, on the contrary, insignificant. Reocclusion of the internal carotid artery demonstrated no significant influence on outcomes of the disease in combined type of the lesion. Reocclusion of the target vessel after thrombectomy significantly decreased the probability of a good functional outcome in patients 1.7-fold (p<0.05), as well as increased the relative risk of disability 4-fold in initially isolated occlusion of the middle cerebral artery (p<0.05). CONCLUSION: Surgical policy aimed at thrombectomy from the middle cerebral artery in the presence of tandem occlusions of the internal carotid artery and middle cerebral artery without emergency carotid stenting is safe and efficient in acute period of ischaemic stroke. Reocclusion of the middle cerebral artery after performed thrombectomy related to its isolated occlusion increased the probability of patients' disability. Newly identified in the postoperative period occlusion of the internal carotid artery in thrombectomy from the middle cerebral artery also increased the risk of disability.

[Peculiarities of diagnosis and emergency surgical care in aorto-oesophageal fistula]. / Osobennosti diagnostiki i neotlozhnoi khirurgicheskoi pomoshchi pri aorto-pishchevodnom svishche.

An aorto-oesophageal fistula is a rare but life-threatening pathological condition developing on the background of diseases of the aorta and oesophagus, as well as after surgical interventions on the aorta. The article deals with a clinical case report regarding management of a patient presenting with an aorto-oesophageal fistula resulting from a thoracic artery aneurysm. The main clinical manifestations of the diseases included dysphagia (due to oesophageal obstruction caused by thrombotic masses of the aneurysm) and the occurring gastrointestinal haemorrhage. Comprehensive instrumental diagnosis was performed using roentgen examination of the oesophagus, oesophagoscopy, and contrast-enhanced computed tomography of the chest. The obtained findings made it possible to objectively assess the patient's state, to carry out timely treatment in conditions of a surgical hospital, and to avoid severe complications.

[Predictors of one-year outcomes after percutaneous coronary interventions in octogenarian patients with acute coronary syndrome.]

Our study presented the long-term outcomes of coronary stenting and predictors of two-year outcomes in octogenarian patients with acute coronary syndrome. A total of 366 patients with STEMI, NSTEMI and unstable angina undergoing percutaneous coronary intervention (PCI). Results were assessed at a median follow up of 20 months. Hospital mortality in the group of patients older than 80 years was 8% and long-term mortality 21%. Chronic renal failure, cardiogenic shock, multi-vessel coronary disease, ejection fraction less than 35, left main coronary artery lesion were independent predictors of mortality. The best prognosis corresponded to those drug-eluting stents use, radial access and GP IIb/IIIa use in patients with ST-segment elevation myocardial infarction. Progression of cardiac and renal failure were the main causes of death during this period. Our results suggested that percutaneous coronary interventions in octogenarian patients with acute coronary syndrome was associated with good clinical and long-term outcomes. DES use, radial access and GP IIb/IIIa use in patients with ST-segment elevation myocardial infarction were associated with improved all-cause mortality in our population.

[Ruptures of popliteal artery aneurysms]. / Razryv anevrizmy podkolennoi arterii.

AIM: To improve diagnosis and surgical outcomes in patients with ruptured popliteal artery aneurysm. MATERIAL AND METHODS: Eight patients with ruptured popliteal artery aneurysm have undergone surgery for the period from 1999 to 2015 at the Vascular Surgery Department of Sklifosovsky Research Institute for Emergency Care. Incidence of rupture was 2.9% from total number of popliteal artery aneurysm. 7 patients with rupture had signs of lower limb ischemia (acute form grade I in 2 (25%) cases, grade IIA in 1 (12.5%), grade IIB in 1 (12.5%) case, chronic ischemia grade IIB in 2 (25%) patients, grade III in 1 (12.5%) patient). 1 (12,5%) patient had not lower limb ischemia. Preoperatively all patients underwent sonography of lower limb arteries and soft tissues, computed tomography of the same structures was carried out in 3 patients, 5 patients underwent subtraction digital angiography. Presence and dimensions of soft tissues hematoma, arterial perfusion proximally and distally to popliteal artery, aneurysms of contralateral limb and other localizations were assessed. RESULTS: Amputations after surgical repair were absent in 6 patients. Five patients were discharged with patent graft, completely compensated blood flow and primary healing of postoperative wound. Severe postoperative complications followed by amputation occurred in 2 patients. One patient died with reperfusion syndrome, hematoma and graft infection, sepsis. CONCLUSION: 1) Ruptured popliteal artery aneurysm is extremely rare complication, however it is a formidable event with high risk of amputation and death. 2) Early diagnosis of popliteal artery aneurysm and surgical treatment prior to embolism, thrombosis and rupture are necessary to prevent formidable complications. 3) Timely detection of aneurysms and their complications by general practitioners is extremely low due to rarity and specificity of the disease, presence of various symptoms. It is necessary to popularize knowledge about this disease among general practitioners. 4) Sonography is screening method for differential diagnosis. 5) CT-angiography or subtraction angiography are advisable to assess distal perfusion if patient's state is stable without severe ischemia. 6) Aneurysm repair with popliteal artery replacement should be performed in early period after rupture in order to reduce time of ischemia and to prevent infection of hematoma in view of ischemia and anemia.

[Treatment of abdominal aortic thrombosis]. / Lechenie bol'nykh s trombozom briushnoi aorty.

AIM: To improve the outcomes in patients with abdominal aortic thrombosis. MATERIAL AND METHODS: 83 patients with acute lower limbs ischemia caused by abdominal aortic thrombosis were enrolled. They have been treated at the emergency vascular surgery department of Sklifosovsky Research Institute for Emergency Care for 10-year period (2006-2016). RESULTS: We described surgical tactics and preferable procedure depending on severity of atherosclerotic lesion, reasons of abdominal aortic thrombosis, lower extremities ischemia severity. CONCLUSION: Timely diagnosis of abdominal aortic thrombosis and surgical treatment are essential to improve the outcomes.

[The features of diagnosis and treatment of traumatic and non-traumatic pulmonary bleeding]. / Osobennosti diagnostiki i lecheniia legochnogo krovotecheniia travmaticheskoi i netravmaticheskoi étiologii.

AIM: To analyze an efficacy of differentiated approach for pulmonary bleeding of different etiology and severity. MATERIAL AND METHODS: The study included 134 cases of pulmonary bleeding for the period 2006-2015 including 53 patients with traumatic and 81 with non-traumatic etiology. Men/women ratio was 2.7:1, mean age was 43 years. Comparative retrospective analysis of X-ray and CT data in diagnosis of bleeding source was performed. Bronchoscopy was used to confirm these data. There were 43 endovascular examinations including 40 cases of bronchial arteriography (BAG). RESULTS AND DISCUSSION: X-ray and CT-signs of bleeding source were detected more often in case of traumatic pulmonary bleeding (62.3% and 93%) compared with non-traumatic (27.2 and 54%; p<0.05). Bronchoscopy revealed ongoing pulmonary bleeding in 40 (30%) patients, completed - in 94 (70%) patients. Indirect angiographic signs were the most frequent for pulmonary bleeding origin: hypervascularization (32.6%), bronchial-pulmonary shunts (23.2%) and bronchial artery dilatation (20.9%). 17 patients with ongoing bleeding underwent bronchial obstruction with adequate hemostasis in all cases. Endovascular interventions included bronchial arteries embolization (EBA) (33), occlusion of intercostal arteries (3) and segmental branches of low-lobar pulmonary artery (1), aortic stenting (1). Early efficacy of EBA was 97% with 2 month recurrence of pulmonary bleeding near 12.5%. Ongoing traumatic pulmonary bleeding was an indication for emergency thoracotomy in 18.9% compared with 12.3% for non-traumatic bleeding when surgery was made after endoscopic and endovascular hemostasis. CONCLUSION: Differentiated approach depending on etiology and severity of pulmonary bleeding improves outcomes and reduces the number of operations for ongoing severe bleeding.

[Use of the "Multitask" device while performing endarterectomy from iliac arteries]. / Ispol'zovanie instrumenta «Multitasc¼ pri vypolnenii endarterektomii iz podvzdoshnykh arterii.

AIM: The study was aimed at assessing efficacy of using the "MultiTASK" device manufactured by the Le Maitre Company while performing extended endarterectomy from iliac arteries in patients presenting with multilevel atherosclerotic lesions of the arterial bed and chronic ischaemia of lower extremities. PATIENTS AND METHODS: We analysed the outcomes of surgical management of a total of 37 patients presenting with multilevel atherosclerotic lesions of the common and external iliac arteries and arteries below the inguinal ligament over the period from 2012 to 2015 at the Department of Emergency Vascular Surgery of the Scientific Research Institute of Emergency Ambulance Care named after N.V. Sklifosovsky. Twenty one (56.8%) patients presented with haemodynamically significant stenoses of the iliac artery. Eleven (29.7%) patients had occlusion of the external iliac artery and five (13.5%) patients presented with occlusion of the common iliac artery in the distal portion. In all cases there was a second block, i. e. occlusion of the superficial femoral artery. RESULTS: The primary patency rate of the external iliac artery after endarterectomy amounted to 100%. Immediate complications directly associated with endarterectomy from the external iliac artery were encountered in one (2.7%) case - during back traction of the loop there occurred perforation of the wall of the external iliac artery by a calcified plaque, thus requiring external-iliac-common-femoral prosthetic repair. Amputation was performed in two (5.4%) patients (in both cases due to thrombosis and the development of ischaemic gangrene owing to poor condition of the distal arterial bed). One (2.7%) patient died of acute myocardial infarction. CONCLUSION: Extended endarterectomy by means of the "MultiTASC" device turned out efficient, yielding good immediate outcomes in atherosclerotic lesions of femoral arteries both as an independent operation and when combined with reconstruction of arteries beneath the inguinal ligament.

[Endovascular and surgical treatment of a patient with traumatic rupture of the aorta and hepatic artery].

Traumatic rupture of the aorta is the second most common cause of death in closed chest injury. The latest findings of autopsy showed that 80% of lethal outcomes in aortic injury occur in the prehospital period. Taking into consideration the incidence and high rate of death prior to the diagnosis stage, aortic rupture in closed thoracic injury is an important problem. Due to the characteristic mechanism of the development (during sharp deceleration of the body) this type of traumatic lesion of the aorta became known as "deceleration syndrome". The most vulnerable to tension aortic portion is its neck where the mobile part of the thoracic aorta is connected to the fixed arch in the place of the arterial ligament attachment. Open surgical intervention in patients with severe closed chest injury (often concomitant injury) is associated with high mortality and complications. Currently endovascular prosthetic repair of the aorta is a method of choice at the primary stage of treatment of patients with aortic injury. In this article we present a rare case report of concomitant lesion of large vessels (the descending aortic portion and proper hepatic artery) in a patient with severe concomitant injury, as well as peculiarities of diagnosis and combined treatment (endovascular prosthetic repair of the aorta and hepatic artery with an aotovein).

[Use of thrombolytic therapy and rheolytic thrombectomy in treatment of pulmonary artery thromboembolism].

The article deals with the results of combined treatment of patients with pulmonary thromboembolism by means of systemic thrombolytic therapy, anticoagulant therapy, and rheolytic thrombectomy during the period from 2012 to 2013. Thrombolytic therapy was used in 78 of 187 patients with the confirmed diagnosis of pulmonary thromboembolism (Group 1). The diagnosis was verified and therapeutic results were controlled by means of contrast-enhanced spiral computed tomography and perfusion scintigraphy. Thrombolysis was carried out using: tissue plasminogen activator - alteplase (61 cases) with administration of the full dose during 2 hours, streptokinase (14 cases) at a dose of 1.5 million IU in the mode of prolonged infusion during 24 hours and urokinase (3 cases) at a dose of 4400 IU/kg during 12 hours. 109 patients were subjected to anticoagulant therapy (Group 2). Five patients were subjected to rheolytic thrombectomy for desobstruction of the pulmonary artery. The method was used in patients with previously performed ineffective or partially effective thrombolytic therapy, as well as in patients with contraindications to thrombolysis. The lethality rate for TLT amounted to 5.4% and that for anticoagulant therapy 26.6%. Probability of a lethal outcome in Group 2 (anticoagulant therapy) turned out to be 6.71 times higher as compared with Group 1 (thrombolytic therapy). In all cases of using rheolytic thrombectomy we managed to achieve a decrease of the Miller index and systolic pressure in the pulmonary artery. Desobstruction of the pulmonary artery was complete in 3 cases. In two cases rheolytic thrombectomy was partially effective and the patients underwent repeat thrombolysis with a good clinical outcome. Using systemic thrombolysis in patients with pulmonary artery thromboembolism demonstrated a positive effect on the prognosis of survival. Rheolytic thrombectomy contributed to improvement of the results of thrombolytic therapy and may be used as an alternative method of treatment.

[Role of multislice computed tomography in the diagnosis of acute rupture of the thoracic aorta and hepatic artery in a patient with severe concomitant injury].

Acute traumatic aortic rupture is associated with extremely high mortality rates and requires emergency diagnosis and treatment. This clinical example shows the role of multislice spiral computed tomography in the emergency diagnosis of rupture of two large arterial vessels in severe concomitant injury. It presents the benefits of this rapid and noninvasive imaging technique, an algorithm of the study and the semiotics of injuries in patients with suspected traumatic aortic rupture. The paper also shows the importance of this method in defining treatment policy and then in the assessment of the results of the performed correction.

[Remote results of endovascular atherectomy with the SilverHawk device].

The authors studied the remote results of 27 endovascular catheter atherectomies performed in 25 patients. All patients had lesions of arteries of the femoropopliteal segment according to the TASC II classification. The duration of follow up varied from 6 to 34 months. Endovascular catheter atherectomy was carried out by means of the SilverHawk EV3 system with protection of the distal bed from embolism using Spider EV3. Our findings prove that catheter atherectomy with the SilverHawk system is most efficient it treatment of short stenotic lesions, lesions localizing in the zone of increased dynamic activity, multi-level lesions of arteries of the femoropopliteal segment, as well as short lesions in patients suffering from diabetes mellitus.

[Comparison of remote results outcomes of stenting and eversion endarterectomy from internal carotid arteries].

Presented in the article are comparative results of carotid angioplasty with stenting (CAS) and eversion carotid endarterectomy (ECEA) in the remote period of follow up. The study included a total of 92 patients. Of these, 33 were subjected to CAS (Group I) and 59 underwent a total of 63 ECEAs (Group II). Depending upon the presence or absence of symptoms of cerebrovascular insufficiency (CVI), as well as based on assessment of risk factors for surgical intervention, the patients were subdivided into four subgroups: a) low-risk asymptomatic b) low-risk symptomatic, c) high-risk asymptomatic and d) high-risk symptomatic. We followed up remote results in 31 Group I patients (94%) up to 70 months (mean period of follow up amounted to 25±17 months), and in 36 Group II patients up to for up to 65 months (mean duration of the follow up amounting to 37±20 months). There was no statistically significant difference (P >0.05) between subgroups of patients along such parameters as severe or mild stroke, myocardial infarction, stroke-related death, or myocardial infarction related death. CAS and ECEA are equally highly efficient techniques of preventing acute cerebral circulation impairments in the remote period of follow up in patients of both high and low risk of surgical intervention.

[The role of multispiral computed tomographic coronarography].

The aim of the study was to assess the use of multispiral computed tomographic coronarography (MSCT-CG) in comparison with conventional coronary angiography. Overall 62 patients aged 45-72 years were examined, the MSCT-CG was conducted in 38 patients. The sensitivity of MSCT-CG was 92%, the specificity - 91,2%, in comparison with the CAG. The prognostic value of negative test was 95,7%, the prognostic value of positive test was 84%, overall accuracy was counted up to 91,5%. Though, the MSCT-CG showed certain overestimation in calculating the stenosis degree and, thus, false positive results, in cases with calcined atherosclerotic plaques. Main advantages of MSCT-CG were: non-invasiveness, possibility of vessel lumen, arterial wall and structure of the plaque assessment.

[Current trends in diagnosis and treatment of arteriovenous angiodysplasia].

A total of 240 patients with arteriovenous angiodysplasia (AVD) were examined and treated in A.V. Vishnevsky Institute of Surgery during 1997-2009. Embolization was performed in 196 (81.7%) patients. Staged embolization was the principal treatment modality in 84 (35%) patients presenting with inoperable lesions. The mean number of sessions was 3.6. Intraoperative embolization using hydrogel embols, Gianturco coils, and 96% alcohol was done in 17 (7.1%) patients. Radical surgery with the removal of angiomatous tissues was given to 33 (13.8%) patients. Palliative resections were made in patients with extensive lesions and impossibility of total removal of angiomatous tissues. Minor and major amputations were needed in 15 patients. It is concluded that intervention for microfistulous and confined macrofistulous lesions should be performed only in case of absolute indications for surgery. That in asymptomatic or subclinical cases is justified only for minor surface lesions fit for radical resection. Minor amputation is indicated in certain patients with arteriovenous fistulas on distal limb segments. Extensive delayed resections should be planned with the use of plastic surgical techniques (autodermoplasty using free flaps, mobilized flaps, and flaps with microvascular anastomosis).

[Surgical management of atherosclerotic-aetiology vasorenal hypertension].

The present retrospective study was carried out to analyse clinical outcomes of 56 surgical interventions performed on renal arteries in a total of 48 patients suffering from atherosclerotic- aetiology vasorenal hypertension (VRH). Of these, 14 patients were subjected to stenting of renal vessels, 19 underwent aortorenal prosthetic repair, 11 patients endured transaortic endarterectomy (TEA), and four cases were treated by resection of the renal artery with reimplantation. The immediate postoperative outcomes turned out positive in 81% of the patients, to have remained so within an average follow-up period of up to 5 years in 72% of the patients. Most often good results were observed after renal artery prosthetic repair (in 85% of patients) and stenting (in 78% of patients). Good results were observed in 26% of patients with a history of VRH over 5 years, with its duration of less than that surgical renal revascularization being accompanied by positive outcomes in 58% of patients.

[Endovascular separation of the arterio-arterial anastomosis between the circumflex branch of the left coronary artery and bronchial artery].

Presented in the article is a case report concerning successful dissociation of an arterio-arterial anastomosis between the circumflex branch of the left coronary artery and bronchial artery using a stent graft in a 72-year-old patient.

[Endovascular occlusion of posttraumatic suprarenal aortic pseudoaneurysm].

Presented in the article is a case report regarding successful treatment of a posttraumatic false aneurysm localizing in the immediate proximity to the superior mesenteric artery, which was isolated by the Amplatzer Duct Occluder II, with the disks diameter measuring 6 mm to allow closure of the patent ductus arteriosus.

Renal artery stenosis: incidence of detection during angiography in patients with peripheral arterial disease.

The purpose of this study was to determine the frequency with which atherosclerotic lesions of renal arteries are detected during diagnostic angiography in patients presenting with peripheral arterial disease. To this was added the assessment of the risk factors for the development of atherosclerotic renal artery lesions (i. e., gender, age, and the level of a concomitant lesion of the lower-limb arteries). The findings obtained in our study revealed that each fourth patient with Leriche's syndrome appeared to have a significant lesion of the renal artery. Female sex was found to be a predictor of renal artery lesions in patients with peripheral arterial disease. Patients presenting with pathology of renal arteries proved significantly older than those having no lesions of renal arteries.