A Specialized device designed for eversion carotid endarterectomy.

Carotid endarterectomy (CEAE) is currently considered to be one of the most efficient methods of treatment for chronic cerebrovascular insufficiency and prevention of recurrent acute impairments of cerebral blood supply. Methodically, the manipulation concerned is in the majority of cases carried out by one of two most commonly employed techniques, i. e., classical CEAE from the longitudinal arteriotomy with plasty with a synthetic patch, and the so-called eversion CEAE implying removal of an atherosclerotic plaque (ASP) by means of eversion of the internal carotid artery (ICA). Many Russian and foreign authors point out indisputable advantages of eversion CEAE, consisting in a shorter duration of ICA clamping, no need to use synthetic materials, preservation of the anatomical geometry of the bifurcation of the common carotid artery (CCA), a lower incidence rate of restenoses in the remote period. Along with it, eversion CEAE also possesses certain disadvantages consisting in namely complicated revision of the distal intima of the ICA (the zone wherein the ASP is tapering), the necessity of traction by the ASP, which may might lead to its premature detachment, impossibility of ICA eversion distal to the endarterectomy zone and repeat eversion of the already endarterectomised portion of the ICA. Hence, eversion carotid endarterectomy still remains the area of skilled and experienced vascular surgeons, thus giving prerequisites for further levelling its technical disadvantages shortcomings, which was the objective of the present study. The authors describe herein a new specially designed surgical device intended to facilitate the operation of eversion carotid endarterectomy, as well as the technique of application thereof. Based on a comparative example comprising a total of eighty-six eversion carotid endarterectomic procedures performed both with and without the new device, we demonstrated efficiency of using the proposed technique.

[Subclavian-femoral bypass grafting in treatment of lower-limb critical ischaemia in an elderly patient with an inoperable thoracoabdominal aortic aneurysm].

The authors describe herein a variant of successful palliative treatment of a 73-year-old male patient suffering from an inoperable thoracoabdominal aortic aneurysm accompanied by coronary artery disease, painless myocardial ischaemia, pathological tortuosity of the left internal carotid artery, type 2 diabetes mellitus, and chronic renal insufficiency. The patient was admitted to the Department of Vascular Surgery presenting with critical ischaemia of his left lower limb, complaining of numbness and gnawing pain both at rest and while walking a distance of up to 10-15 metres, demonstrating portions of skin ischaemia up to 2 cm long on the anterior surface of the femoral upper third, clinical signs of a thoracoabdominal aortic aneurysm, the presence of a pulsating formation in the projection of the infrarenal portion of the abdominal aorta measuring 5x6 cm. The diagnosis was made based on the findings of instrumental examination, ultrasonography, multispiral computed tomographic angiography, and coronarography, having confirmed the following: a thoracoabdominal aortic aneurysm, occlusion of the left common artery and anterior iliac artery, coronary artery disease, painless myocardial ischaemia, pathological kinking of the left internal carotid artery, chronic renal insufficiency, and type 2 diabetes mellitus. The first stage of the operation to perform consisted of mammary- coronary bypass grafting of the anterior interventricular artery from the left anterior lateral thoracotomy. Despite certain improvement in the condition of the coronary bed, the patient remained inoperable due to the presence of pronounced multipleorgan pathology and a high risk of lethal complications. Given these circumstances, the second stage of the intervention consisted in performing a palliative operation of subclavian-femoral bypass grafting on the left with a reinforced polytetrafluoroethylene stent graft.

[The effect of carotid endarterectomy on cognitive disturbances in patients with atherosclerotic stenosis of carotid arteries].

Clinical and neuropsychological features of non-dementia cognitive disturbances were studied in 102 patients with atherosclerotic carotid stenosis. Cognitive disturbances were assessed after the carotid endarterectomy (CEAE). Mild cognitive impairment was found in 37 (36,3%) of patients, moderate cognitive impairment was diagnosed in 36 (35,3%)patients. Moderate cognitive impairment was found more often in patients with symptomatic carotid stenosis with structural brain changes confirmed by neuroimaging data and with instable atherosclerotic plaques with the predomination of hypodensity component. It allows to suggest that both the reduction of perfusion and arterio-arterial microemboli may cause cognitive dysfunction in patients with atherosclerotic carotid stenosis. The data on the positive effect of CEAE on cognitive functions have been obtained. The positive changes were more distinct in patients with asymptomatic course of carotid stenosis. However CEAE may have a negative effect on cognitive functions in patients with moderate cognitive impairment of dysmnestic character and symptomatic carotid stenosis.

[Gigantic aneurysm resulting from pathological kinking of the internal carotid artery].

Described in the article is a case report of successful surgical management of a 50-year-old male patient presenting with a gigantic aneurysm of the right internal carotid artery, pathological tortuosity of the right and left internal carotid arteries, successfully treated by resection of the aneurysm of the right internal carotid artery with autovenous prosthetic repair of the right internal carotid artery.

[Transection of secondary chordae of anterior mitral valve leaflet as a method of correction of functional mitral insufficiency during resection of left ventricular aneurism].

Dominating factor of development of functional mitral insufficiency in patients with ischemic heart disease and dilated cardiomyopathy is deformation of atrioventricular valve leaflets due to traction by chordae apparatus. In patients candidates for left ventricular reconstruction because of its postinfarction aneurism the problem of preexisting or recurrent dysfunction of mitral valve acquires special value as operation itself implies surgical ventricular remodeling and therefore change of mitral valve geometry. Supplementation of the volume of surgical intervention with resection of chordae responsible for impaired coaptation of mitral valve leaflets in some cases appears to be effective and simple method of correction of mitral insufficiency.

[Plasma lipids oxidation in patients with occlusive atherosclerosis of lower extremities and ischemic heart disease].

Dynamics of lipoprotein oxidation in blood plasma was studied by Cu-induced plasma oxidation in 114 patients with atherosclerosis of lower extremities of various severity with and without ischemic heart disease. Preparedness of plasma lipoproteins to oxidation in patients was higher than in healthy subjects. Degree of oxidizeability increased with increase of severity and extent of atherosclerosis and was highest in patients with atherosclerosis of lower extremities and ischemic heart disease. There were no significant differences between groups of patients with various severity and extent of atherosclerosis in levels of total cholesterol and triglycerides as well as in other parameters of lipid spectrum. Correlation analysis revealed no relationship between age of patients and degree of plasma oxidizeability.

[Mini-invasive technologies in diagnosis and treatment of major vessels diseases].

Experience with 150 endovascular stents and endoprostheses including ones of vertebral and carotid arteries (first experience in Russia) is analyzed. Mini-invasive surgery is indicated for patients with isolated arterial lesions (segmental stenosis, short occlusions), changed and hard for surgery parts of vascular system (renal, visceral arteries, branches of aortic arch), restenosis after traditional surgeries and also for patients with severe concomitant diseases. Rate of complications of carotid endovascular stenting was 4,3%. The follow-up ranged from 2 months to 5,5 years. There were no restenoses in the stented zone. Complete absence of complains and regress of neurological symptoms were seen in 89% patients.

[Potential of tomographic methods of diagnosis and three-dimensional analysis of abdominal aortic aneurysm images]. / Vozmozhnosti tomograficheskikh metodov diagnostiki i trekhmernogo analiza izobrazhenii anevrizm briushnoi aorty.

Between 1998 and 2002, 256 tomographic investigations of the abdominal aorta were performed. Aortic aneurysms were identified in 29 (11.3%) patients. Computed tomographic angiography (CTA) was provided to 16 patients 4 patients were examined by an electron-radiation tomograph, 6 by a spiral tomograph, 6 by a multispiral tomograph, and 13 patients underwent magnetic resonance angiography (MRA), with contrast enforcement. Two- and three-dimensional reconstructions of CT- and MR-angiograms were accomplished using special computerized working stations. Good quality MR- or CT- angiograms were obtained in all the patients examined. Interpretation of the angiograms did not cause noticeable difficulties. None of the patients required conventional contrast angiography. The investigations have demonstrated the benefits of multispiral CTA recognized as the method of choice for the diagnosis of aortic aneurysms. Of the 29 patients with the verified diagnosis of aneurysm of the abdominal aorta, aneurysms in 26 subjects were located in the infrarenal aorta. Of these, 5 patients were identified to have an aneurysm extending to the iliac arteries. In two patients, aneurysms extended to the renal arteries or to the suprarenal segment. A thoracoabdominal aneurysm (type III) was revealed in one patient. Associated aneurysm and occlusive lesions of lower extremity arteries (iliac, femoral) were present in 15 (51.7%) cases. In the majority of cases (89.7%), aneurysms ran an uncomplicated course. The complications encountered by us consisted in incomplete (intramural) rupture (2 patients) and dissection (one patient). 22 patients were operated on. Comparison of the intraoperative revision data with the results of preoperative CT and MR angiography has established that the sensitivity of the tomographic methods for the diagnosis of aneurysms was 95.7% and specificity 99%. With an accuracy of up to 2-3 mm there were determined the size of aneurysms, the distance to the renal arteries, the diameter of the proximal and distal "neck", the extension of aneurysms to the iliac arteries, the presence of occlusive lesions of lower extremity arteries. CT and MR angiography with bolus contrast enforcement are safe and noninvasive methods for the diagnosis of aortic aneurysms. They have the high information content and thus allow to plan surgical (and possibly endovascular) interventions without the use of conventional contrast angiography.

[Comparative assessment of the results of open carotid endarterectomy and carotid aftery stenting]. / Sravnitel'naia otsenka rezul'tatov otkrytoi karotidnoi éndarteréktomii i stentirovaniia sonnykh arterii.

A comparative study of 48 carotid stent grafting and 23 open carotid endarterectomies was carried out. Patients of both groups were comparable by cerebrovascular insufficiency degree and concomitant diseases. General rate of complications after carotid stent grafting (CSG) was 5.1%. There was a small ischemic stroke with right-sided hemiparesis and aphasia in one patient during CSG. Complete regress of the neurological symptoms was seen on the 5th day. In the nearest postoperative period after CSG there was a big ischemic stroke in the territory of MCA in one patient. Rate of complications after open carotid endarterectomy (OCEAE) was 8.7% Transient ischemic attacks were seen in 2 patients in early postoperative period. Paresis of the IX cranial nerves was in one patient. In long-term postoperative period after CSG 2 patients died due to cardiac causes. One patient died 18 months after OCEAE due to ischemic stroke. In long-term period after OCEAE restenosis of the internal carotid artery was seen in 4.5% cases, while there were no restenosis after CSG. It is concluded that CSG is an effective method of treatment of carotid stenosis with lower lethality and postoperative complications rate compared with OCEAE. Indications for CSG are symptomatic stenosis of ICA (>60%), asymptomatic stenosis of ICA(>70%), two-sided lesions of the carotid arteries, carotid stenosis with lesions of other brachiocephalic arteries, insufficiency of Willis circle.

[Diet regimes in acute pancreatitis]. / Rezhim pitaniia pri ostrom pankreatite.

A method of determination of the duration of curative fasting in acute pancreatitis, depending on the degree of severity of patients' condition is described. The dependence between the probability of exacerbation of the process after resumption of feeding, the degree of severity of the condition at admittance, the duration of the fast vs degree of the severity of the condition in which the feeding was resumed was studied, for this purpose the method for calculation of so called coefficient of the degree of severity of acute pancreatitis was developed. 130 patients with acute pancreatitis underwent the treatment according to this method.

[The dynamics of blood serum middle-molecule peptides in the prognosis of the course of acute pancreatitis]. / Dinamika srednemolekuliarnykh peptidov syvorotki krovi v prognozirovanii techeniia ostrogo pankreatita.

The work is devoted to studying the dynamics of endogenous toxemia by the level of middle mass peptides of blood serum in patients with acute pancreatitis. The level of middle mass peptides was investigated in 116 patients spectrophotometrically after Gabriélian with the wave length 254 nm (1st fraction, MMP-1) and with the wave length 282 nm (2nd fraction, MMP-2). It was found that the ratio of these fractions could be used as a prognostic index of the complicated course of acute pancreatitis. When the initial ration MMp-2/MMP-1 is less that 1 the risk of the development of complications of the second phase of acute pancreatitis is real. The decrease of the level of MMP-1 and MMP-2 during treatment by the 3rd-4th days is considered to be an indicator of the favorable outcome of the disease. The elevation of the level of MMP-1 and MMP-2 by the 3rd-4th days despite the treatment predicts an unfavorable outcome of the disease.

[Reconstructive surgery in injuries of major arteries and veins]. / Rekonstruktivnye operatsii pri raneniiakh magistral'nykh arterii i ven.

Retrospective analysis of surgical treatment for injuries of 408 major arteries and veins in 352 patients in the department of vascular surgery of N.V. Sklifossovsky Research Institute of Emergency Care from 1989 to 1996 is presented. Of 126 cases of prosthetic reconstructions in 72.2% autoveins were used, in 18.3%--synthetic prosthesis, and in 9.5% homologous arterial biologic prosthesis. Good results were obtained in 13.1% of patients, amputations were made in 4.8%. Lethality was 4.0%. Principles of treatment of combined injuries, prophylaxis of syndrome of inclusion and other complications are autlined.

[Choice of optimal policy for treatment of acute pancreatitis]. / Vybor ratsional'noi taktiki lecheniia ostrogo pankreatita.

662 case records of patients with acute pancreatitis are analysed and principles for the choice of optimal treatment of patients with acute pancreatitis (AP) are established. The most justified policy in treatment of AD patients seems to be conservative-expectant. The treatment should satisfy the phases of the course of acute pancreatitis and severity of the disease. At the first stage of the disease the treatment should be aimed at correction of pancreatic toxemia and prophylaxis of pyogenic complications. Surgical interventions at this phase are risky and hardly justified. If there are indications for drainage, laparoscopy and small invasive interventions under US control are preferable. At the second stage conservative-expectant policy should be also used as a method of choice, and treatment should be aimed at prophylaxis of purulent complications. The presence of aseptic necroses are not an absolute indication for surgery if there are no clear signs of suppuration. The presence of purulent complications is an indication for surgical treatment; extraperitoneal approaches to pyogenous areas and their drainage by wide two-lumen tubes for the following use of aspiration--lavage treatment are more preferable.

[Determination of indications for curative-diagnostic laparoscopy with the use of index of seriousness in patients with acute pancreatitis]. / Opredelenie pokazanii k lechebno-diagnosticheskoi laparoskopii s pomoshch'iu znacheniia koeffitsienta tiazhesti bol'nykh ostrym pankreatitom.

The effective curative-diagnostic laparoscopy in acute pancreatitis depends on the time of its performance and on the seriousness of the disease. The use of special mathematical formulas and nomograms makes it possible to improve results of the treatment.

[Physiotherapeutic methods in the postoperative period in acute pancreatitis patients]. / Fizioterapevticheskie metody v posleoperatsionnom periode u bol'nykh ostrym pankreatitom.

60 patients surgically treated for acute pancreatitis received postoperative physiotherapy which combined transcutaneous electroneurostimulation with exposure to low-energy laser. The results support the effectiveness of combined physiotherapeutic methods of general and reflex action in severe forms of acute pancreatitis because such physiotherapy early after severe forms of acute pancreatitis because such physiotherapy early after severe pancreatitis surgery promotes the decline of pathological symptoms.