[Clinical study of efficacy and safety of Aducil in patients with chronic lower limb ischaemia]. / Klinicheskoe issledovanie éffektivnosti i bezopasnosti Adutsila pri khronicheskoi ishemii nizhnikh konechnostei.

AIM: The study was aimed at assessing efficacy and safety of treatment with Aducil® (cilostazol) compared with Trental® 400 in patients with moderate-to-severe intermittent claudication due to peripheral atherosclerosis. PATIENTS AND METHODS: The study included a total of one hundred and forty-five 36-to-75-year-old patients. The participants were distributed into 2 groups according to the inclusion/exclusion criteria in a 2 to 1 proportion: patients in group 1 received Aducil® 100 mg BID, in group 2 - Trental® 400 TID for 12 weeks. 142 subjects completed the protocol. RESULTS: Analysis of the effectiveness of treatment according to the primary criterion showed a better effectiveness of Aducil® as compared with Trental® 400. Subjects who received Aducil® had a higher increase in the absolute maximum walking distance after 12 weeks of treatment as compared with those taking Trental® 400: 126±110 m versus 45±39 m, respectively (р<0.001). Subjects who received Aducil® had a statistically significant improvement in quality of life parameters such as physical and mental health components according to the SF-36 questionnaire after 12 weeks of treatment (р≤0.01). Subjects in Aducil® group had better quality of life with an increase from 34 to 40 points according to the physical component score, while patients in Trental® 400 group demonstrated minor positive changes (from 35 to 37 points); mean mental component score increased from 45 to 48 points in Aducil® group as compared with an increase from 45 to 47 points in Trental® 400 group. While self-reported physical health status was similar between the groups at baseline, subjects in Aducil® group reported better physical functioning after treatment (р=0.016). Two adverse events were registered in two subjects in Aducil® group. CONCLUSION: Analysis of the study endpoints demonstrated that Aducil® had better treatment effectiveness in patients with chronic lower limb ischemia stage IIB according to the classification of A.V. Pokrovsky-Fontaine as compared with Trental® 400, while the safety profile and drug tolerance were similar between the two.

[Present-day possibilities of non-invasive control over microcirculation and metabolism in man]. / Sovremennye vozmozhnosti neinvazivnogo kontrolia mikrotsirkuliatsii i obmena veshchestv u cheloveka.

The main function of the microcirculatory bed consists in maintaining tissue homeostasis at an optimal level irrespective of the effect of various external and internal factors. Of all types of metabolism (diffusive, filtration-reabsorption and vesicular), directly dependent on the haemodynamic parameters is filtration-reabsorption metabolism which provides exchange of water, low-molecular-weight and water-soluble substances at the opposite to the heart «pole¼ of the cardiovascular system. The present study was aimed at testing a hypothesis that activation of metabolic processes in man would be accompanied by alterations in haemodynamic parameters which may be registered by means of modern non-invasive methods of examination, i. e., laser Doppler flowmetry (LDF) and computer-assisted capillaroscopy (CCS). We used actovegin as an activator of metabolic processes. The study included acute pharmacological testing in apparently healthy volunteers (n=28), a course of taking actovegin in patients with cognitive dysfunctions on the background of arterial hypertension (n=60) and in patients with chronic ischaemia of the lower limbs (n=80). The obtained findings of LDF and CCS demonstrated that the known metabolic effects of actovegin (improved utilization of oxygen and glucose by tissues) were accompanied by an increase in the number of functioning capillaries, increased velocity of capillary blood flow with a decrease in the degree of hydration of the interstitial space, thus reducing the «blood-cell¼ distance for nutrients and products of tissue metabolism. Improvement of capillary blood flow was determined by a decrease in the tonicity of the capillary sphincters, thus leading to reduced arteriolar-venular shunting of blood with predominant supply to the capillary bed, improved NO-mediated regulation of the value of the lumen of the precapillary arterioles by the microvascular endothelium, improved reaction of resistant microvessels to various dilatation stimuli. The obtained results make it possible to draw a conclusion that modern non-invasive methods of study of human microcirculation (LDF and CCS) are informative not only for assessment of the functional state of the microcirculatory bed of the skin but make it possible to evaluate efficacy of the filtration-reabsorption mechanism of metabolism.

[Effect of drug therapy for chronic obliterating diseases of lower-limb arteries on the state of the microcirculatory bed].

UNLABELLED: Search for an optimal method of conservative treatment of patients presenting with chronic obliterating disease of lower limb arteries (CODLLA) still remains an important and hitherto unsolved problem. Comparative studies of different drugs and objective assessment of their efficacy may be carried out using the method of laser Doppler flowmetry (LDF) with wavelet analysis of fluctuations in blood flow. OBJECTIVE: The study was aimed at assessing efficacy of using Actovegin in conservative treatment of patients presenting with chronic obliterating disease of the lower extremities induced by occlusive and stenotic lesions of the arterial bed. MATERIAL AND METHODS: The study included a total of 80 patients with stage 2B chronic ischaemia of the lower limbs. The patients were subdivided into two groups. Group One comprised 40 patients undergoing a course of intravenous infusions of Actovegin (at a dose of 250 ml, 4 mg/ml) as monotherapy for 10 days. Group Two comprised 40 patients receiving intravenous infusion of dextranes, as well as pentoxyphyllin at a dose of 100 mg/day. The state of microcirculation before and after the course of the infusion therapy was assessed by means of LDF with wavelet analysis of blood follow fluctuations. The basal blood flow was registered at a temperature of + 32° C for 10 minutes followed by a thermal test, i. e., heating to + 42oC for 30-40 minutes. RESULTS: The course of infusion therapy in Group One patients was followed by an increase of the amplitude of myogenic fluctuation by 56% (p=0.006) and a decrease in the index of blood flow shunting (p=0.1) with basal perfusion, as well as an increase in the maximum level of perfusion (p=0.006). Group Two patients showed were found to have only statistically significant shortening of the time of reaching the maximum level of thermal hyperaemia. The increase of the pain-free walking distance averagely amounted to 58.8% in Group One patients and 60.7% in Group Two (p=0.068). Patients of the both groups showed satisfactory tolerance of the carried out therapy. No undesirable adverse events were observed. CONCLUSION: LDF with wavelet analysis of fluctuations of blood flow makes it possible to thoroughly study the mechanisms of action of therapeutic agents on microcirculation in patients with CODLLA . The use of Actovegin as monotherapy in CODLLA patients leads to a decrease in the myogenic tonus of precapillary arterioles and capillary sphincters, to a decrease in the arteriolar-venular shunting of blood flow with predominant supply of blood to the capillary bed, to an increase in the oxide-synthase function of the endothelium of microvessels (endothelioprotective effect), as well as to an increase in the maximum level of thermal vasodilatation. Hence, Actovegin may be considered as a promising therapeutic agent for pharmacotherapy of CODLLA.

[Cardiosynchronized sequential antegrade pneumocompression in treatment of patients with multifocal atherosclerosis].

The work was aimed at assessing efficacy and safety of indications for and contraindications to a promising method of treatment for multifocal atherosclerosis - enforced external counterpulsation, suggesting a new noninvasive method of treatment of chronic obliterating diseases of lower-limb arteries - cardiosynchronized sequential antegrade pneumocompression.

[Experience with hybrid techniques of surgical treatment of patients with lower limb critical ischaemia].

The authors present their original experience with the use of hybrid techniques of surgical treatment in a total of 19 patients with lower limb critical ischaemia (LLCI) on the background of complex lesions of the arteries of lower extremities. They describe various types of hybrid techniques of surgical treatment of patients with critical ischaemia on the background of chronic obliterating diseases of lower-limb arteries. Also discussed are 3 varieties of clinical situations in which it is appropriate to employ the hybrid method: thrombosis of the bypass graft, multi-storey lesions of lower-limb arteries, and the use of a hybrid technique in order to decrease the size of the surgical wound. The period of follow up varied from 2 to 36 months. The limbs were saved in all the patients during the whole follow-up period. Two patients were found to have thrombosis of the reconstructed segment after 1.5-5 months.

[Peculiarities of performing hybrid operation in a patient with atherosclerosis of lower limbs and developed critical ischaemia].

Currently, there is a tendency towards an increase in the incidence rate of cardiovascular disease. According to the data of the World Health Organization the incidence rate of obliterating diseases of peripheral arteries varies from 5 to 10%. Diseases of peripheral arteries manifest themselves by such a severe condition as lower-limb critical ischaemia. Most often lower-limb chronic critical ischaemia develops in patients with multi-level lesions of the arterial bed. Treatment of such patients constitutes a serious problem since it requires large-scope revascularization. The authors describe a clinical example of a hybrid operation in a patient with atherosclerosis of lower-limb arteries on the background of critical ischaemia of the lower extremities on the background of type 2 diabetes mellitus. The hybrid intervention was performed in the scope of balloon angioplasty and stenting of the right deep femoral artery with simultaneous loop semiclosed thromboendarterectomy from the right common femoral artery, superficial femoral and popliteal artery with balloon angioplasty of the right superficial femoral artery with mechanic recanalization and balloon angioplasty of the popliteal artery, anterior tibial artery, and peroneal artery. The next stage consisted in amputation of the anterior portion of the right foot according to the Chopart s technique with skin plasty. Resulting from the operation on the background of further angiotropic and rheological active therapy with PGE-1 preparation VAP-20 we managed to save the patient s limb and to limit to minor amputation. Hybrid operative interventions should be carried out in order to achieve maximal revascularization when it is not possible to obtain a favourable result by a reconstructive or endovascular intervention alone.

[A clinical example of operative intervention on previously stented peripheral artery in a patient with critical ischaemia of lower limbs].

The problem of open surgery of peripheral arteries after previously performed interventions is currently of considerable interest. This is associated with the development of roentgenoendovascular technologies, on the one hand, and with the fact that it is not always possible to use them properly, on the other. Nowadays, one may single out a small group of patients having endured balloon angioplasty and stenting of the arterial segment followed by open operation. Of special interest are patients with critical ischaemia of lower extremities. No results of randomized studies dedicated to this problem have yet been published. The present article deals with a clinical case concerning a patient having endured multiple interventional therapeutic procedures including stenting of the iliac-femoral segment. The consequent development of critical ischaemia of lower limbs required emergency revascularization by an open method on the previously stented vessels. The duration of postoperative follow up is more than 12 months.

[Management of thrombotic occlusions of femoropopliteal bypass grafts treated by a combined method].

Presented in the article are two clinical case reports concerning remote results of successful surgical management of thrombotic occlusions of femoropopliteal bypass grafts treated by a combined method. The first stage of surgical treatment in both cases in the roentgen-equipped operation room consisted in open thrombectomy of the shunt, with the second stage being endovascular recanalization - in the first case balloon angioplasty of the proximal and distal anastomosis and in the second case - balloon angioplasty and stenting of the distal anastomosis, distal arterial bed.

[Comparative characteristics of the open and endovascular methods of treatment for carotid artery stenoses].

The article is dedicated to the problem concerning treatment for stenoses of the extracranial portions of carotid arteries. From March 2004 to November 2009 at the Department of Vascular Surgery No 2 of the N. A. Semashko Central Clinical Hospital No 2 we treated a total of 364 patients presenting with stenotic lesions of the extracranial portion of the carotid arteries. Of these, 176 patients underwent revascularization of the carotid basin: 120 patients endured open carotid endarterectomy (CEAE), 56 patients sustained carotid angioplasty and stenting (CAS), with a total of 128 CEAE and 67 CAS interventions performed. The following conclusion was made: with high skill of surgeons and broad experience in carrying out revascularization of the carotid basin, the CEAE and CAS procedures possess comparable efficacy and safety with CEAE possessing reliable advantage in terms of the parameters of the patient's quality of life.

[Administration of prostaglandin E1 in the treatment of patients with chronic lower limbs critical ischemia with concomitant ischemic heat disease]. / Lechenie bol'nykh s khronicheskoi kriticheskoi ishemiei nizhnikh konechnostei s primeneniem prostaglandina E1 na fone soputstvuiushchei ishemicheskoi bolezni serdtsa.

Drug treatment of chronic lower limbs critical ischemia (CLLCI) remains an important problem, particularly in patients with concomitant ischemic heart disease treated with prostaglandins E1 (PGE1). Experience in treatment of these patients with alprostadil is presented. Symptoms of a high risk of coronary events are demonstrated, prophylactic measures are proposed.

[Disorders of rheologic properties of blood and their correction in postthrombophlebitic syndrome]. / Narushenie reologicheskikh svoistv krovi i ikh korrektsiia pri posttromboflebiticheskom sindrome.

Pathogenetic mechanisms of disorders of rheologic properties of blood in postthrombophlebitic syndrome (PTPS) are analyzed. Thirty-six patients were examined and divided into 2 groups. In combined therapy of the study group (18 patients) pentoxyfillin tablets were included. In the control group derivatives of xantin were used. Good clinical effect of pentoxyfillin based on positive influence on rheologic properties of blood was demonstrated. In the study group significant reduction of edema was in 72,2% patients, of pains - in 83,3%. In the control group positive results were achieved only in 55,6% patients.

[The diagnosis of vasculogenic impotence as a consequence of pathological venous drainage of the corpora cavernosa]. / Diagnostika vaskulogennoi impotentsii vsledstvie patologicheskogo venoznogo drenazha kavernoznykh tel.

A total of 184 patients with suspected impaired venous drainage of cavernous bodies were examined. Dynamic perfusion cavernosography with cavernometry was employed. Venous drainage abnormalities were detected in 158 of 184 examinees. Classification of this drainage abnormalities was elaborated based on the results of these examinations. A drug perfusion method for determining debit deficiency, one of the basic parameters of this classification (together with run-off type), has been developed.

[The risk prediction of erectile failure developing after the reconstruction of the aortoiliac segment]. / Prognozirovanie riska razvitiia érektsionnoi nedostatochnosti posle rekonstruktsii aortopodvzdoshnogo segmenta.

The authors suggest their method for prognosticating the risk of formation of erectile incompetence after reconstruction of the aortoiliac segment. In 78 patients with Leriche's syndrome and maintained erectile function 13 qualitative parameters were determined before the operation (the degree of intermittent claudication, the duration of the disease of the lower limbs, the results of ultrasonic dopplerography and angiography), which were then converted to quantitative discrete characteristics. The obtained set of characteristics was used for prognosticating the condition of the sexual function after the operation by means of the familiar methods of regressive analysis on a personal PS/XT computer according to a program of multidimensional regression in the packet of programs. Clinical tests confirmed the high accuracy of the prognosis of the value characterizing the condition of the sexual function by this method. Such prognostication makes it possible to substantiate with high authenticity the expediency of combined revascularization of the lower limbs and cavernous bodies of the penis and opens real prospects of improving its results.

[The prognosis of the efficacy of revascularization of the penile corpora cavernosa in the surgical treatment of Leriche's syndrome]. / Prognozirovanie éffektivnosti revaskuliarizatsii kavernoznykh tel polovogo chlena pri khirurgicheskom lechenii sindroma Lerisha.

The authors have developed a procedure for predicting the efficiency of penal spongy body revascularization in surgical management. Thirteen qualitative parameters, such as duration of sexual dysfunction, libido, having a sexual intercourse partner, degree of intermittent claudication, duration of lower extremity diseases, penal erection angle after drug test and ultrasound Doppler echography with drug test, were evaluated in 36 patients with Leriche's syndrome and erectile dysfunction. The qualitative parameters obtained were converted to quantitative discrete characteristics. The set of characteristics was used to predict the postoperative parameter--the value characterizing the sexual function by using the well-known methods of regression analysis on a PS/XI personal computer by the multiple regression programme in the Statgraphics program package. The high accuracy of prediction of the value characterizing the sexual function by this method makes it possible to substantiate the expediency of penal spongy body revascularization and opens up new ways for improving its outcomes.

Surgical treatment and prevention of vasculopathic impotence in conjunction with revascularisation of the lower extremities in Leriche's syndrome.

The results are presented of combined revascularization of the lower extremities and the penis in 29 patients with Leriche's syndrome. This was effected by placing an autogenous venous shunt between the branch of a prosthesis or the common femoral artery and one of the dorsal arteries of the penis. Preoperatively lost sexual function was restored in 6 patients, while in 16 the sexual function was maintained at the preoperative level or improved in the late postoperative period. A comparison of the results obtained with the sexual performance of patients who had undergone bifurcated aortofemoral shunting only, prompted the conclusion that this surgical procedure was effective in the prevention and treatment of vasculopathic impotence in Leriche's syndrome.

[A new method of surgical treatment of vasculogenic impotence]. / Novyi sposob khirurgicheskogo lecheniia vaskulogennoi impotentsii.

The authors describe a method of surgical management of vasculogenic impotence consisting in the formation of an anastomosis of an autovenous shunt with the dorsal artery of the penis. To prevent revascularization of the cavernous bodies of the penis with the restoration of erection, the dorsal artery of the penis is divided transversely at the root of the penis, the distal end of the autovenous shunt is given the shape of a trapezium with the upper side sutured, after which the autovenous shunt is anastomosed end to end with both the distal and proximal segments of the dorsal artery of the penis at the lateral sides of the trapezium where the angles were not sutured. The method allows incompetence and thrombosis of the vascular anastomosis to be prevented, raises the efficacy of revascularization of the cavernous bodies of the penis by creating favourable hemodynamic conditions through separation of the blood flow into the distal and proximal segments of the dorsal artery of the penis, which provides retrograde supply of blood into the deep artery of the penis sufficient for adequate revascularization of the cavernous bodies.

[Surgical treatment and prevention of angiogenic impotence in combination with revascularization of the lower extremities in Leriche's syndrome]. / Khirurgicheskoe lechenie i profilaktika vaskulogennoi impotentsii v sochetanii s revaskuliarizatsiei nizhnikh konechnostei pri sindrome Lerisha.

The article deals with the results of combined revascularization of the lower limbs and penis in 29 patients with Leriche's syndrome. It was accomplished by creating an autovenous shunt between the blades of the prosthesis or common femoral artery with the dorsal artery of the penis. In the late-term postoperative period the initially lost sexual function was restored in 6 patients and improved or maintained on the preoperative level in 16 patients. On the basis of comparison of the results with the sexual function in patients who were treated by bifurcation aortofemoral shunting it is concluded that the suggested surgical tactics in the prevention and treatment of vasculogenic impotence in Leriche's syndrome produces a significant clinical effect.