[Acute mesenteric ischemia - a 15-year experience of surgical treatment in a multi-field hospital]. / Ostraya arterial'naya mezenterial'naya ishemiya ­ 15-letnii opyt khirurgicheskogo lecheniya v mnogoprofil'nom statsionare.

OBJECTIVE: To evaluate the results of surgical treatment of arterial acute mesenteric ischemia in a single hospital over a 15-year period (from 2007 to 2022). MATERIAL AND METHODS: There were 385 patients with acute occlusion of superior or inferior mesenteric artery over a 15-year period. The causes of acute mesenteric ischemia were thromboembolism of superior mesenteric artery (51%), its thrombosis (43%) and thrombosis of inferior mesenteric artery (6%). Female patients predominated (258 or 67%), while male patients comprised 33% (n=127). Age of patients ranged from 41 to 97 years (mean 74±9). The main diagnostic method for acute intestinal ischemia was contrast-enhanced computed tomography or CT angiography. Intestinal revascularization was performed in 101 patients: 10 patients - open embolectomy or thrombectomy from superior mesenteric artery, 41 patients - endovascular intervention, 50 patients - combined surgery (revascularization with resection of necrotic bowel segments). Isolated resection of necrotic intestines was performed in 176 patients. Exploratory laparotomy was performed in 108 patients with total bowel necrosis. Prevention and treatment of reperfusion and translocation syndrome after successful intestinal revascularization implied extracorporeal hemocorrection for extrarenal indications (veno-venous hemofiltration or veno-venous hemodiafiltration). RESULTS: Overall 15-year mortality rate (385 patients) for acute SMA occlusion was 71% (256 out of 360 patients), postoperative mortality excluding exploratory laparotomies for the same time period - 59%. Mortality rate for inferior mesenteric artery thrombosis was 88%. Routine CT angiography of mesenteric vessels, active and effective early intestinal revascularization (open or endovascular surgery), as well as extracorporeal hemocorrection methods for reperfusion and translocation syndrome reduced mortality rate to 49% over the past 10 years (from 2013 to 2022). Mortality in acute mesenteric ischemia in the first 5 years of this study (from 2007 to 2012) was 64% (p=0.16). The main cause of death was intestinal gangrene with multiple organ failure. Reperfusion syndrome after effective endovascular revascularization complicated by severe pulmonary edema and acute respiratory distress syndrome resulted death in 15% of patients. CONCLUSION: Acute mesenteric ischemia is followed by high mortality rates and extremely poor prognosis. Early diagnosis of acute intestinal ischemia using modern diagnostic methods (CT angiography of mesenteric vessels), effective revascularization of superior mesenteric artery (open, hybrid or endovascular), prevention and treatment of reperfusion and translocation syndrome can improve postoperative outcomes.

[Gas in superior mesenteric artery and celiac axis as a rare CT-sign of extensive bowel necrosis]. / Gaz v verkhnei bryzheechnoi arterii i chrevnom stvole kak redkii KT-priznak obshirnogo nekroza kishechnika.

The authors report endovascular treatment of acute thromboembolic occlusion of superior mesenteric artery in a 75-year-old patient whose postoperative period was complicated by massive reperfusion and translocation syndrome. Contrast-enhanced CT in 12 hours after successful thrombectomy from superior mesenteric artery revealed CT signs of irreversible bowel lesion, i.e. gas in hepatic veins, intestinal wall and mesenteric veins, bowel wall thinning. In addition, CT revealed extremely rare sign of severe acute mesenteric ischemia (gas in superior mesenteric artery and celiac axis). We found no description of gas in celiac axis following acute mesenteric ischemia in available literature.

[Venous thromboembolic complications in patients with intracerebral hemorrhage]. / Venoznye tromboembolicheskie oslozhneniya u patsientov s gemorragicheskim insul'tom.

OBJECTIVE: To evaluate the effectiveness and safety of various heparin therapy regimens for venous thromboembolic complications in patients with acute cerebral circulatory disorders of the hemorrhagic type. MATERIAL AND METHODS: In a prospective single-center study, treatment results of 62 patients with hypertensive brain hematoma were analyzed. All patients were divided into two comparable groups: the group of «very early¼ prophylactic heparin therapy or the first 48 hours from the moment of the disease (n=35) and the group of «early¼ prophylactic heparin therapy, or later than 48 hours from the moment of the intracerebral hematoma development (n=27). The end points of the study were: venous thrombosis, pulmonary embolism (fatal and non-fatal), recurrent intracerebral hemorrhage, other clinically significant hemorrhagic complications, and intrahospital mortality. RESULTS: In the group of «very early¼ and «early¼ prophylactic heparin therapy, the results were as follows: venous thrombosis 22.9% vs. 29.6% (p=0.36), total rate of PE 2.9% vs. 11.1% (p=0.03), nonfatal PE 0% vs. 7.4% (p=0.007), fatal PE 2.9% vs. 3.7% (p=0.76), recurrent intracerebral hemorrhage and other hemorrhagic complications 0% in both groups, intrahospital mortality was 54.3% versus 48.1% (p=0.54). CONCLUSION: The earliest administration of direct anticoagulants in prophylactic doses in patients with hemorrhagic stroke leads to the decrease in the frequency of venous thrombosis and thromboembolic complications, without being accompanied by the development of repeated intracranial and other hemorrhagic events.

[Carotid endarterectomy and carotid artery stenting in advanced age patients]. / Karotidnaya endarterektomiya i stentirovanie vnutrennei sonnoi arterii u patsientov starshikh vozrastnykh grupp (obzor literatury).

The manuscript is devoted to world experience of carotid endarterectomy and carotid artery stenting in advanced age patients. Some authors report the advantages of endovascular surgery in elderly patients while the others prefer carotid endarterectomy. Senile patients (75-80 years old) with asymptomatic internal carotid artery stenosis is one of the most difficult group for the management. This is due to a more complex assessment of perioperative surgical risk, high incidence of complicated atherosclerotic plaques in carotid arteries and dubious benefits of surgery considering short life expectancy and severe comorbidities. Accumulation of experience in the management of advanced age patients should be valuable for either optimizing or individualizing surgical strategy.

[Treatment of patients with a cerebral arterial aneurysm and stenosis of the internal carotid artery]. / Lechenie patsientov s anevrizmami arterii golovnogo mozga i stenozom vnutrennei sonnoi arterii.

AIM: The purpose of this study was to analyse the world literature dedicated to the problem concerning treatment of a combination of internal carotid artery stenosis at the extracranial level and an arterial aneurysm of the brain, as well as to demonstrate own results of surgical treatment of patients presenting with this concomitant pathology of the carotid basin. PATIENTS AND METHODS: From 2013 to 2019, a clinical course of combined pathology of the basin of the internal carotid artery (an intracranial aneurysm and stenosis of the internal carotid artery at the extracranial level) was revealed in 35 of 1638 examined patients. There were ten men and 25 women, with a mean age of 66±7 years. In all the 35 patients, intracranial aneurysms appeared to be asymptomatic and were revealed during diagnosis of an atherosclerotic lesion of the internal carotid artery. Fifteen (43%) of the 35 patients were operated on. A two-stage surgical approach was used in 2 patients with ipsilateral location of the cerebral aneurysm and stenosis of the internal carotid artery: the first stage consisted in clipping of the arterial aneurysm, with stage 2 being carotid endarterectomy. A vascular stage alone (carotid endarterectomy or stenting of the internal carotid artery) was carried out in 9 patients, with a neurosurgical stage alone (clipping of the aneurysm) in 4 patients. RESULTS: The incidence of internal carotid artery stenosis with an arterial cerebral aneurysm, according to our findings, amounted to 2.1%. In the group of surgical treatment, in 1 case (6.7%) after stenting of the symptomatic stenosis of the internal carotid artery a female patient with an ipsilateral asymptomatic aneurysm of the middle cerebral artery intraoperatively developed 'minor' ischaemic stroke. Neither perioperative aneurysmal ruptures nor lethal outcomes were observed in the group of patients subjected to surgical interventions. CONCLUSION: An individual tactical approach to patients presenting with a combination of a cerebral aneurysm and internal carotid artery stenosis at the extracranial level made it possible at this stage of the work to avoid both intracranial haemorrhagic complications and lethal outcomes. The frequency of perioperative ischaemic cerebral events amounted to 6.7%. Further collection of the clinical material is needed to work out an optimal surgical policy in a combined lesion of the extra- and intracranial basin of the internal carotid artery.

[Endovascular surgery for acute mesenteric ischemia]. / Éndovaskuliarnaia khirurgiia ostrogo arterial'nogo narusheniia mezenterial'nogo krovoobrashcheniia: podkhody k lecheniiu.

OBJECTIVE: To demonstrate the results of endovascular treatment of 15 patients with acute mesenteric ischemia. MATERIAL AND METHODS: There were 15 patients with acute mesenteric ischemia who underwent surgery (9 men and 6 women). Mean age was 77±11 years. Acute intestinal ischemia was caused by thromboembolism of superior mesenteric artery (9 patients), thrombosis of superior mesenteric artery (5 patients) and critical stenosis of the ostia of superior mesenteric artery and celiac trunk (1 patient). Mean time from clinical manifestation of disease to admission to the hospital was 13 hours (range 2-72 hours). In-hospital development of acute mesenteric ischemia was noted in 2 patients. Indications for endovascular intervention and techniques of endovascular revascularization of superior mesenteric artery are described in the article. RESULTS: Blood flow restoration in superior mesenteric artery was achieved in 14 (93%) out of 15 patients. Laparotomy was required in 4 (27%) patients for extensive resection of necrotic intestine (n=1, 6.7%), local resection of small bowel (n=2, 13%). In another (6.7%) patient, intestine was recognized as viable after laparotomy. A bulk of intestine was preserved in most patients (n=14, 93%). In-hospital mortality rate was 47% (7 patients died). The main cause of nosocomial death (6 cases) was reperfusion syndrome followed by respiratory distress syndrome and multiple organ failure. CONCLUSION: New methods of prevention and treatment of reperfusion syndrome can improve the results of treatment of acute mesenteric ischemia.

[Results of endovascular treatment of acute tandem occlusion of internal carotid and middle cerebral arteries]. / Rezul'taty endovaskulyarnogo lecheniya ostroi tandemnoi okklyuzii vnutrennei sonnoi i srednei mozgovoi arterii.

OBJECTIVE: To evaluate the results of endovascular treatment of patients with ischemic stroke caused by acute tandem occlusion of the internal carotid and middle cerebral arteries (ICA and MCA). MATERIAL AND METHODS: Endovascular intervention was performed in 8 patients with tandem occlusion of ICA and MCA. The neurological deficit on admission was 17.4±5.6 NIHSS points and the average ASPECTS score was 9.5±0.8. The time from the onset of neurological symptoms to reperfusion was 224±68 min. Thrombolytic therapy was initiated before brain revascularization and continued intraoperatively in 4 out of 8 patients. ICA stenting after aspiration thrombectomy was required in 6 patients. Both antegrade (n=4) and retrograde (n=2) methods of brain revascularization were used. RESULTS: The rate of detection of tandem lesion in patients with ischemic stroke who underwent endovascular treatment was 5.4%. Technical success in restoring blood flow in the ICA basin at extra-and intra-cranial levels (mTICI 2b/3) was achieved in 7 (87.5%) patients. Intracranial hemorrhagic complications that affected the outcome of the disease were clinically significant in 25% of patients (n=2). The mortality rate was 37.5% (n=3). A satisfactory clinical result (a deficit of 0-2 mRS scores) was achieved at discharge in one of 5 surviving patients. CONCLUSION: Further studies of choosing the optimal surgical tactics for tandem occlusion of ICA and MCA, taking into account its effectiveness and safety, are need.

[Endovascular treatment of tandem occlusion of internal carotid and middle cerebral arteries in acute ischemic stroke]. / Éndovaskuliarnoe lechenie tandemnoi ostroi okkliuzii vnutrennei sonnoi i srednei mozgovoi arterii pri ostrom ishemicheskom insul'te.

The paper presents the literature data concerning the results and surgical approaches to the treatment of tandem occlusion in the ICA system. The authors describe two clinical cases of endovascular treatment of tandem ipsilateral occlusion of ICA and middle cerebral artery (MCA). In both cases, the cause of two-level occlusion was complicated by thrombosis atherosclerotic plaque in ICA in the extracranial part with distal thromboembolism in SMA. The antegrade endovascular approach was used in both patients, when ICA was stented at the first stage, and at the second stage aspiration thrombectomy from SMA was performed. The period from the onset of symptoms to revascularization of the ICA system was 285±63 minutes. There were no fatal outcomes, patients were discharged with different neurological deficits: scores of the first patient were as following: 2 points on the NIHSS, 1 point on a Rankin scale, 13 points (initial 12 points on NIHSS) on the Rivermead mobility index and of the second patient: 14 points on the NIHSS, 5 points on a Rankin scale, 0 points (of the original 17 points on the NIHSS) on the Rivermead mobility index.

[Therapeutic policy in stenosis of the internal carotid artery combined with intracranial vascular malformation]. / Taktika lecheniia stenoza vnutrennei sonnoi arterii v sochetanii s intrakranial'noi sosudistoi mal'formatsiei.

Presented herein is the world experience of surgical treatment and various tactical approaches in a combined lesion of the extracranial and intracranial portions of the internal carotid artery (ICA): a combination of its stenosis or occlusion with vascular malformation of the brain (a cerebral aneurysm, pathological anastomoses, arteriovenous malformations). Also pointed out is the prevalence of the pathology involved, followed by describing various types of surgical policy in this condition: staged and simultaneous interventions, endovascular and standard operative auxiliary techniques. Taking into consideration a low incidence rate of combined pathology of the ICA, there are currently no randomized studies that would make it possible to work out a common tactical approach to management of this cohort of patients. Hence, this vascular and neurosurgical problem appears to require further study.

[Endovascular interventions in treatment of patients with acute impairment of mesenteric blood circulation]. / Éndovaskuliarnye vmeshatel'stva v lechenii bol'nykh s ostrym narusheniem mezenterial'nogo krovoobrashcheniia.

The authors share herein their experience of treating a total of eight patients with acute impairment of mesenteric blood circulation, describing both technical and instrumental peculiarities of interventions on the superior mesenteric artery. Technical success defined as restoration of the main blood flow through the superior mesenteric artery was achieved in seven (87.5%) patients. Of these, two (25%) patients required laparotomy and intestinal resection, with the scope of resection being significantly reduced in one case after endovascular thrombectomy. A further two (25%) patients developed respiratory distress syndrome as a complication of reperfusion syndrome. There were two (25%) lethal outcomes. A conclusion was drawn that endovascular interventions might be regarded as an independent method of treatment of patients presenting with acute impairment of the mesenteric blood flow in the stage of intestinal ischaemia. Besides, this technique makes it possible in case of the development of intestinal gangrene to dramatically diminish the scope of intestinal necrotic lesion.

[Outcomes of open endovascular operations on the internal carotid artery in acute stage of ischaemic stroke]. / Rezul'taty otkrytykh i éndovaskuliarnykh operatsii na vnutrennei sonnoi arterii v ostroi stadii ishemicheskogo insul'ta.

INTRODUCTION: The authors share their experience in diagnosis and treatment of patients with acute ischaemic stroke. PATIENTS AND METHODS: The study included a total of 33 patients. Of these, 20 patients (Study Group) were operated on at terms ranging from 2 to 7 days after onset of acute cerebral circulatory impairment. The Control Group was composed of 13 patients with ischaemic stroke, having refused surgical prevention of recurrent stroke. Both groups were matched by age, gender, level of neurological deficiency and size of cerebral ischaemic foci. Surgical management in the Study Group consisted in either carotid endarterectomy (n=15) or stenting of the internal carotid artery (n=5). Depending on the severity of coronary artery lesion and the presence of accompanying therapeutic pathology, options of operative treatment with various anaesthesiological support were offered. RESULTS: At discharge, neurological deficit in the Study Group patients was lower - 1.2 points by the NIH Stroke Scale versus 2.7 points in the Control Group, however, this difference was not statistically significant (p=0.45). In the Study Group there were two complications: haematoma of the postoperative injury requiring its revision and a transient ischaemic attack during stenting of the internal carotid artery, having disappeared on the operation table after the distal cerebral protection device was removed. Significantly better results were obtained by the following parameters: in the Study Group the number of patients discharged with no neurological deficit (scoring 0 by the NIHSS scale) was significantly higher compared with the Control Group; 50% vs 7.7% (p<0.001). There were no lethal outcomes in either group. One patient (7.7%) from the Study Group developed recurrent ischaemic stroke, whereas neither intra- nor postoperative stroke was registered in the Control Group patients (p<0.001). CONCLUSIONS: In carefully selected patients with ischaemic stroke (neurological deficit not exceeding 3 points by the Rankin scale and not more than 11 points by the NIHSS, with the size of the ischaemic focus not exceeding 4 cm), surgical prevention of recurrent stroke within 7 days after the onset of an ischaemic event may be performed effectively and safely. Early operation effectively prevents relapsing ischaemic events at the in-hospital stage. Besides, reconstruction of brachiocephalic arteries during an acute stage of stroke in operated patients improves the neurological status in the postoperative period, decreases the degree of motor and sensory disorders and makes it possible in half of patients to completely eliminate neurological deficit present at admission.

[Diagnosis and treatment of extracranial internal carotid artery lesion combined with cerebrovascular malformation]. / Diagnostika i lechenie porazhenii ékstrakranial'nogo otdela vnutrennei sonnoi arterii v sochetanii s sosudistoi mal'formatsiei golovnogo mozga.

AIM: To analyze own experience of diagnosis and treatment of patients with extracranial internal carotid artery lesion and cerebrovascular malformations. MATERIAL AND METHODS: There were 16 patients with combined lesion of extracranial and intracranial internal carotid artery for the period January 2013 - December 2014. Occlusive-stenotic lesion and tortuosity of ICA were observed in 11 and 5 cases respectively. RESULTS: Incidence of combined ICA lesion was 5.2% (16 out of 308 observations of extracranial internal carotid artery lesion). Surgical treatment was performed in 7 patients including two-stage intervention in 4 cases and simultaneous surgery in 3 cases. Mean time between neurosurgical and vascular stages was 6 months. Complications and mortality were absent. CONCLUSION: Two-stage surgical approach with intracerebral vascular malformation correction followed by extracranial ICA reconstruction may be safe and effective in patients with combined lesion of ICA. Further trials are necessary for certain conclusions.

[Early reconstruction of brachiocephalic arteries as a prevention of recurrent ischemic stroke]. / Ranniaia rekonstruktsiia brakhitsefal'nykh arterii kak profilaktika povtornogo ishemicheskogo insul'ta.

AIM: To assess an efficacy and safety of brachiocephalic arteries reconstruction at the acute stage of stroke. MATERIAL AND METHODS: Early reconstruction of brachiocephalic arteries was made in 7 patients (mean age 67±9 years). Mean terms of brachiocephalic arteries reconstruction after stroke were 4.6 days (range 2-7 days). Pre- and postoperative neurological state was assessed by NIHSS score (mean preoperative score was 3.9±2.7 in these 7 patients, range 0-7). All patients had ipsilateral cerebral ischemic lesions with stenosis/occlusion of brachiocephalic artery. Their mean dimension was 10 mm (range 4-32 mm). Internal carotid artery stenting was made in 2 patients, carotid endarterectomy - in 4 patients, stenting of the 1st segment of left subclavian artery - in 1 patient. RESULTS: There were no deaths and recurrent postoperative ischemic strokes. Complications developed in 2 patients: postoperative hematoma and intraoperative transient ischemic attack during ICA stenting in 5 days after stroke. There was a positive course of neurological state after brachiocephalic arteries reconstruction: mean score of neurological deficit decreased by almost 2 times (from 3.9±2.7 to 2±1.7). CONCLUSION: Early surgical prevention (within 7 days after stroke) may be effective and safe in certain patients with ischemic stroke (neurological deficit by Rankin score ≤3 and NIHSS ≤7, ischemic focus dimension less than 4 cm). Brachiocephalic arteries reconstruction early after stroke improves neurological state postoperatively by reducing motor and sensitive disorders. However, at present time there are no clear indications for early revascularization depending on either neurological deficit severity and ischemic focus dimension. So, our data should be confirmed by large trials.

[Stenting of the superior mesenteric artery in a patient with severe chronic intestinal ischaemia].

Presented herein is a clinical case report concerning endovascular treatment of severe chronic ischaemia of digestive organs in a patient with lesions of all three visceral arteries. Peculiarities of endovascular technique in mechanical revascularization of the superior mesenteric artery are described. Restoration of blood flow through even one visceral artery, i. e., superior mesenteric artery, is an effective and safe method of treatment for chronic intestinal ischaemia.

[Early reconstruction of supra-aortic vessels as a prevention of recurrent ischemic stroke]. / Rannyaya revaskulyarizatsiya golovnogo mozga kak profilaktika povtornogo ishemicheskogo insul'ta.

AIM: To evaluate the efficacy and safety of supra-aortic vessels reconstruction within acute period of stroke. MATERIAL AND METHODS: Early surgery was performed in 7 patients aged 67±9 years. Revascularization was made after 4.6 days after ischemic stroke on the average (range from 2 to 7 days). Neurological status before and after surgery was assessed using NIHSS scale, mean preoperative score was 3.9±2.7 (0-7). All patients had ischemic brain lesions (4-32 mm, mean 10 mm) unilateral with carotid stenosis or occlusion. Carotid artery stenting was performed in 2 patients, carotid endarterectomy - in 4 patients and stenting of segment I of the left subclavian artery was made in 1 case. RESULTS: There were no mortality and recurrent postoperative ischemic stroke. Complications occurred in two patients: postoperative hematoma and intraoperative transient ischemic attack that developed during CAS after 5 days of a stroke. There was positive neurological dynamics after revascularization: there was almost 2-fold decrease of mean score of neurological deficit (from 3.9±2.7±1.7 to 2). CONCLUSION: Early surgical prevention of recurrent stroke (up to 7 days) can be performed effectively and safely in carefully selected patients with ischemic stroke (neurological deficit less than 3 Rankin scores and less than 7 NIHSS scores, ischemic lesion dimensions lass than 4 cm). Reconstruction of supra-aortic vessels in acute stage of stroke improves the neurological status and reduces the degree of motor and sensory disorders. However, currently there are no clear criteria for inclusion and exclusion of patients for early revascularization using both degree of neurological deficit and size of ischemic lesion. So our results need to be confirmed by large trials.

[Endovascular interventions for acute ischemia of intestine].

It is presented 5 clinical observations of acute ischemia of intestine in which different endovascular interventions including isolated superior mesenteric artery stenting, rheolytic and aspiration thrombectomy and combination of techniques were applied. Surgical success with blood flow restoration in superior mesenteric artery was achieved in 4 of 5 patients. 2 patients have required laparotomy and intestinal resection. In 1 case extent of resection was significantly reduced after previous endovascular thrombectomy. There were no deaths. It is concluded that endovascular interventions may be considered as independent method of treatment of patients with acute mesenteric ischemia.

[Experience in diagnosis and treatment of combined lesions of the extra- and intracranial portions of the internal carotid artery].

The treatment policy concerning patients with lesions of the extra- and intracranial portions of carotid arteries is currently uncertain. The authors share herein their experience in diagnosis and treatment of 5 patients presenting with lesions of the extracranial portions of the internal carotid artery (stenosis/occlusion/pathological tortuosity) combined with arterial aneurysms and arteriovenous malformations of the brain. Of these, two patients were operated on: the first one was primarily subjected to clipping of the cerebral aneurysm then after several months underwent a reconstructive vascular operation on the ipsilateral side (resection of the internal carotid artery with its readdressing). The second patient with subtotal stenosis of the internal carotid artery who initially underwent clipping of the ipsilateral asymptomatic aneurysm of the middle cerebral artery developed occlusion of the internal carotid artery by the second stage of treatment and was not subjected to vascular operation. There were no is-chaemic cerebral complications or lethal outcomes in the operated patients in peri- and post-operative periods at all stages of treatment.

[Modern approach to diagnosis and treatment of acute mesenteric ischemia].

It was proposed the medical and diagnostic tactic in patients with acute mesenteric ischemia on basis of efficiency results of modern laboratory markers and instrumental methods. Positive laboratory D-dimer-test with computed tomography of abdominal organs or abdominal aorta and its branches CT-angiography led to diagnose thrombosis or embolism of mesenteric arteries at early terms and to reduce preoperative period. The authors presented the variant of isolated endovascular intervention in case of superior mesenteric artery thrombosis. This technique may be regarded as the method of choice in the treatment of patients with acute mesenteric ischemia.