[Remote results of veno-venous bypass operations in post-thrombotic disease].

The present study was aimed at analyzing the remote results of the operation of cross-over autovenous bypass at terms varying from 2 to 28 years in a total of 68 patients presenting with unilateral post-thrombotic occlusive lesions of iliac veins and in 12 patients operated on for obstruction of the femoral vein (saphenopopliteal bypass grafting). The obtained findings showed that a decisive factor of successful cross-over bypass grafting was a sufficient diameter of the autovenous transplant (not less than 7-8 mm). It was determined that in 70.6% of patients the cross-over bypass grafts become dilated with time and thus provide adequate outflow of blood from the affected extremity. Studies of the phlebodynamics in the diseased limb under the conditions of an open and cross-clamped shunt demonstrated that in 72% of patients the main function on carrying out venous return is performed by a cross-over shunt. Some shunts (20.7%) undergo pathological transformation in the form of deforming ectasias and cicatricial stenosis, which in many cases deteriorates the conditions of the outflow of blood and requires secondary surgical correction of the shunts. These operations were successfully performed in patients in the remote terms. Patency of the grafts at 15 years of follow up amounted to 79.6%. There was significant improvement of the outcomes of the bypassing operation observed in application of distal arteriovenous fistulas. A permanent clinical effect was achieved in 74.4% of patients with the functioning shunts. Patency of the saphenopopliteal shunts within the follow-up terms up to 12 years amounted to 91.7%. The remote results showed their reliable function and improvement of the regional phlebodynamics. It was determined that the shunts could function for a long time, not undergoing pathological ectasia. Forty-eight patients during dynamic follow up were subjected to operations on superficial and perforant veins with predominant application of minimally invasive technologies.

[Endoprosthetic repair with stent grafts in coronary artery restenosis].

Timely performed reconstructive operations on carotid arteries considerably decrease the incidence rate of ischaemic-type acute impairments of cerebral circulation. Nevertheless, restenoses developing in the zone of reconstruction of carotid arteries level the positive result of the primary operation in remote terms of follow up. In such cases it is more preferable to perform stenting of the damaged portions. The article deals with cases of successful use of self-expandable stent grafts in restenoses of carotid arteries after carotid endarterectomy and operations of prosthetic repair of carotid arteries. The analysis was carried out by international publications concerning this problem.

[In situ aortofemoral reconstructions in surgical treatment of infected aortofemoral grafts].

The article presents a review of literature sources covering possibilities of peiforming in situ aortofemoral reconstructions in surgical treatment of infected aortofemoral grafts. This methodology makes it possible to improve the outcomes of treatment for paraprosthetic infection at the expense of decreasing lethality and morbidity, increasing parameters of patency of grafts and lower limb salvage in the remote postoperative period. Mention should be made that in situ secondary aortofemoral reconstructions are fraught with danger of relapsing paraprosthetic infection, therefore many publications are dedicated to search for prostheses most resistant to infection. The article also presents the results of works devoted to the use of various types of prostheses for in situ secondary aortofemoral reconstructions: prostheses made of polytetrafluoroethylene (PTFE), synthetic grafts saturated with various antibacterial drugs and gelatine, cadaveric allografts, synthetic prostheses treated with silver ions, autovenous conduits based on the femoral and popliteal veins.

[A role of carotid endarterectomy in prevention of cerebral ischemic damage]. / Znachenie karotidnoi éndarteréktomii v preduprezhdenii ishemicheskikh povrezhdenii golovnogo mozga.

Authors present a literature review on the prevalence, clinical presentations, diagnosis and outcome of surgical treatment of atherosclerotic stenosis of the internal carotid artery.

Surgical management of multiple posttraumatic arteriovenous fistulas of femoral vessels.

Presented herein are two case reports concerning surgical management of posttraumatic arteriovenous fistulas of femoral vessels. Case 1. A 45-year-old female patient attended with a history of a shotgun injury wound of her left femur and crus sustained when a girl of eight. She sought medical attention for a progressively deteriorating condition, accompanied by pain, and breathlessness dyspnea at rest. Detected were multiple fistulas between the deep femoral artery and superficial femoral artery and femoral vein. Management consisted in separation of the arteriovenous fistulas, followed by prosthetic repair of the deep femoral artery. Case 2. A 32-year-old male patient after an accidentally inflicted shotgun injury of the his left femur underwent within a time period of 3 year three vascular operations including ligation of the deep femoral artery and femoral vein followed by having later on developed secondary lymphedema of his left lower limb and pronounced manifested chronic venous insufficiency. Management included dissociation of the numerous arteriovenous fistulas between the branches of the deep femoral artery and the common femoral artery, as well as between the superficial femoral artery and femoral vein.

Surgical correction of varicose vein disease under micronized diosmin protection (results of the Russian multicenter controlled trial DEFANS).

The paper presents the results of DEFANS trial (Detralex - assessment of efficacy and safety for combined phlebectomy). The study enrolled 245 patients with varicose vein disease, who underwent unilateral combined phlebectomy. The main group (n=200) received micronized diosmin (Detralex, 1000 mg/day) for 2 weeks before and 30 days after the procedure; control group (n=45) did not receive Detralex in pre- and postoperative period. Pain severity by 10-point visual analog scale (VAS), an area of subcutaneous hemorrhage in the zone of femoral great saphenous vein resection (by original 12-point scale) and subjective feelings of limb heaviness and fatigability were evaluated 7, 14 and 30 days after the procedure. Subjective symptoms and the area of subcutaneous hemorrhage were significantly lower in the main group, then in control: 7 days after the procedure VAS score was 2.9 and 3.5, respectively; hemorrhage area - 3.4 and 4.6 points, respectively. The same trend was observed for limb heaviness and fatigability, evidencing the better exercise and orthostatic tolerance among patients of the main group in early postoperative period. Quality of life assessment by CIVIQ failed to reveal statistically significant difference between main and control groups in 4-weeks postoperative follow-up. Micronized diosmin in pre- and postoperative period after plebectomy helps to attenuate pain syndrome, to decrease postoperative haematomas and accelerate their resorption, to increase exercise tolerance in early postoperative period.

Arterialization of the hand venous system in patients with critical ischemia and thrombangiitis obliterans.

The lesion of distal arteries in patients with thrombangiitis obliterans happened to looking for nondirect methods of blood supply improvement of the involved limb - transplantation of omental pedicle, arterialization of veins, thoracic sympathectomy, etc. From 1986 in the Department of vascular surgery of A. V. Vishnevsky Institute of Surgery we use method of arterialization of the venous system in patients with critical lower limb ischemia of differ etiology. Practically at the same time we applied this operation for patients with critical upper limb ischemia and thrombangiitis obliterans. In this paper we present our successful experience of 5 operations - arterialization of the hand venous system in 4 patients with thrombangiitis obliterans and critical upper limb ischemia. We reviewed in details the technique of performance of arterialization of the hand venous system and studied the long-term results of the treatment.

Ultrasonic endarterectomy for long superficial femoral artery atherosclerotic occlusive disease.

OBJECTIVE: To report the long term results of ultrasonic superficial femoral artery endarterectomy (USFAE). DESIGN: Retrospective study. PATIENTS AND METHODS: From January 1998 to June 2004 218 USFAE were performed in 202 selected patients (178 males, 192 procedures) with a median age of 65 years (46-87 years). Indications for operation were disabling intermittent claudication in 137 procedures (68%), rest pain in 24 procedures (12%), and limb salvage in 41 procedures (20%). The new medical technology of ultrasonic endarterectomy is based on the application of the mechanical vibrations in the range of low frequency ultrasound. The ultrasonic device consists of the ultrasonic generator, acoustic unit and the flexible wave concentrators with special working tips in the shape of a ring. Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning. RESULTS: The mean follow-up time was 30.1 months. The mean length of the endarterectomised SFAs was 29 cm (range, 15-43 cm). The five year cumulative primary patency rate by means of life table analysis was 45.8 +/- 4.4% (SE). Percutaneous transluminal balloon angioplasty and surgical re-interventions were performed in thirty three and five patients respectively resulting in a primary assisted patency rate of 57.5 +/- 4.1%. The five year secondary patency rate was 65.6 +/- 3.8%. Limb salvage was achieved in 35 of the 41 patients with gangrene. CONCLUSIONS: The long term results of ultrasonic SFA endarterectomy suggest this is an effective technique.

General moderate hypothermia in the surgical treatment of descending thoracic aortic aneurysms.

The diagnosis and surgical treatment of aneurysms of the descending thoracic aorta is difficult and some aspects of management remain controversial. We report 53 patients treated in the period 1983-1988; 25.9% of them had previously been erroneously diagnosed as having mediastinal cysts or tumours. Duplex scanning and computerised tomography were valuable adjuncts in establishing the correct diagnosis, which was confirmed by aortography in 52 patients. Of 49 patients operated upon electively three died with a mortality rate of 6.1%; of the 4 patients operated upon as emergencies 2 died. Fifty patients survived the operative procedure and of the 3 operated upon under normothermia 1 developed paraplegia, whereas of the 47 patients operated upon under moderate hypothermia (30 degrees-31 degrees C) only 1 developed paraplegia.

Recanalisation of occluded peripheral arteries by excimer laser.

Laser recanalisation was attempted in 24 patients with total segmental occlusions of the lower extremity arteries and the aortic arch branches. All patients were men aged 40-82 years, in 20 the lesions were caused by atherosclerosis, in three by Buerger's thromboangiitis and in one by postembolic occlusion. Angioplasty was performed using excimer lasers with a wavelength of 308 nm and with monofiber waveguides in the transcutaneous transcatheter mode. Recanalisation of the vessel throughout the length of the obliterated segment was successful in 13 out of 24 patients. In all patients with thromboangiitis, energy losses were less than in atherosclerotic occlusions and no problems were experienced in patients with severe calcification. A high percentage of failures is a result of imperfect technology and low effectiveness of control, this must be improved. The Vishnevsky Institute of Surgery in collaboration with the Institute of General Physics has been developing a method of recanalisation of occluded arteries using excimer laser radiation. This paper is a preliminary analysis of our first clinical results.

Spontaneous atherosclerotic plaque and obstruction of distal anastomosis in femoral artery. Comparative morphologic study.

The morphology of unaffected intima, atherosclerotic plaque, and postoperative obstructions of the distal anastomosis of the human femoral artery was studied by light and immunofluorescence microscopy. It was established that a focal thickening at the site of the distal anastomosis is identical with an atherosclerotic plaque in structure and localization of certain extracellular matrix components. A distinctive feature of the intimal thickening at the site of the distal anastomosis is the presence of an organized thrombus. These data suggest that obstruction of the distal anastomosis occurs due to the development of an atherosclerotic plaque complicated by an organized thrombus.

Surgical treatment of occlusive lesions of thoraco-abdominal aortic segment.

Forty-nine patients with the occlusive lesions of the thoraco-abdominal aortic segment, congenital hypoplasia (13 patients) and non-specific aortitis (36 patients) were operated on. Operations were performed under moderate hypothermia (+30-31 degrees C) through the left thoracophrenolumbotomic approach. In the majority of patients reconstruction of the aorta was done by means of its resection and replacement. In 9 patients with congenital hypoplasia we performed aortic reconstruction only, and in 4 it was combined with plastic procedure on the coeliac trunk. In 25 patients with non-specific aorto-arteritis aortic replacement was combined with revascularization of the visceral (renal) arteries. In this group reconstruction of the aorta and visceral branches was performed in 7 cases, that of the aorta and renal arteries in 62 and simultaneous reconstruction of the aorta, visceral and renal arteries in 16 cases. Total mortality was 6.1% (3 patients). There was no mortality in patients with aortic hypoplasia.

Classification and surgical treatment of dissecting aortic aneurysms.

A classification of dissecting aortic aneurysms is presented. It allows one to determine more accurately any given pathology in any patient. It helps the surgeon select the most appropriate operative variant and to define tactics of treatment. For example, to discuss the necessity of repeated reconstruction. Our clinical cases have confirmed it.

Surgical treatment of vasorenal hypertension in nonspecific aorto-arteritis (Takayasu's disease).

The authors present a series of 128 patients with vasorenal hypertension secondary to nonspecific aorto-arteritis. Seventy two patients have been operated upon. This is the largest series of patients so far recorded in the literature. In the preliminary diagnosis of VRH nuclide renography plays an important role, as well as intravenous urography and angiography. To define operative indications and choice of operative treatment additional methods are of value: determination of renin activity in the renal veins and nuclide renography under conditions of induced hypotension. Of 72 operated patients only 5 had primary nephrectomy; in 67 patients (90.3%) revascularization of the kidneys was performed, 42 patients had one-stage reconstruction of the aorta or its branches (visceral or renal). For reconstruction of the renal arteries dacron grafts and transaortic endarterectomy have been most often used. Good and excellent results in the immediate postoperative period have been noted in 91.8% of patients and in the late period (at 1-14 years) in 82.3%, this fact points to the efficacy of operative treatment. In recent years (1975-1979) postoperative mortality has been reduced to 3.7% as the result of improved and modified operative technique and proper choice of surgical approach.

Surgical treatment of chronic occlusive disease of the enteric visceral branches of the abdominal aorta. Experience with 119 operations.

Whenever abdominal circulatory disorders are caused by obstruction of the abdominal aortic visceral branches, adequate blood flow may be restored only by surgical intervention. With the development of symptoms suggesting inadequate collateral circulation and disturbance of splanchnic blood supply, operation is indicated. The choice of operation depends on the nature and the cause of the disease and the type of occlusion. With intravascular obstruction, correction of blood flow may be achieved by a reconstructive procedure. In many patients with extravascular compression of the celiac artery, adequate flow is restored by simple external decompression. The present communication is based on experience with 119 operations, 102 reconstructive and 17 decompressive. Of the 102 reconstructive procedures, 94 were complex with one-stage revascularization of several arteries. Transaortic endarterectomy as described in our method of choice although with widespread lesions resection and replacement is preferred. A thoracolumbar approach is the most expedient incision for reconstruction. The results obtained provide evidence for the effectiveness of surgical treatment of chronic occlusive disease of the visceral branches of the abdominal aorta.