[Combined treatment of complicated forms of angiodysplasias in conditions of a multimodality hospital].

Presented herein is a case report dealing with successive combined treatment for arteriovenous malformation of the left part of the chest, macrofistular form complicated by necroses of the left thoracic portion with arrosive haemorrhage from the area of necrosis. The authors describe diagnosis of this disease, technical peculiarities of performing transcatheter endovascular occlusion and topical treatment of wounds, underlining difficulties of verifying the pathology concerned at the prehospital stage and prevention of complications. Particular emphasis in management of these patients is placed upon therapeutic decision-making. Radical excision of tissue practically completely consisting of dilated thin-walled vessels may result in massive perfuse haemorrhage and is often impossible. Selective exclusion of feeding arteries by endovascular methods frequently leads to formation of necroses, does not differ in radical nature because of the presence of multiple arteriovenous fistulas and requires regular follow up of the patient due to a possibility of relapse. The final therapeutic decision should be made in the context of a particular patient, since there are no versatile approaches to management of the pathology concerned.

[Case report of spine and spinal cord injury].

We present a case report of spine and spinal cord injury caused by wound to the face by a foreign body followed by its penetration to cervical soft tissues and lateral compression of the spinal canal by the foreign body causing a neurological deficit. A significant regression of neurological disorders was observed after the dislocation of the vertebra had been eliminated.

[Remote results of endovascular revascularization in patients with lower limb critical ischaemia (LLCI) kept on chronic haemodialysis]. / Otdalennye rezul'taty éndovaskuliarnoi revaskuliarizatsii u bol'nykh s kriticheskoi ishemiei nizhnikh konechnostei, nakhodiashchikhsia na khronicheskom gemodialize.

The study was aimed at assessing remote results of endovascular treatment of patients presenting with lower limb critical ischaemia (LLCI) and kept on chronic haemodialysis. We retrospectively analysed the results of endovascular interventions in a total of 16 patients with ischaemic defects of the foot being on chronic haemodialysis, performed from 2001 to 2012 at the Department of Roentgenosurgical Methods of Diagnosis and Treatment of the St. Petersburg Scientific Research Institute for Emergency Ambulance Care named after I.I. Dzhanelidze. The patients' age varied from 39 to 75 years (mean 56.2±12.8 years). There were 11 (68.7%) men and 5 (31.3%) women. Ten patients (62.5%) suffered from diabetes mellitus. Of the ten diabetic patients, nine (56.2%) received insulin. A total of 21 endovascular interventions were performed on 16 extremities. The obtained findings were statistically processed by means of the Kaplan-Meier method. During follow up, LLCI relapses were observed in eleven (68.7%) patients, amputation of the femur was performed in eight (50%) patients, and five (31.2%) patients survived without major amputation. One year and two years after intervention, the probability of LLCI relapse absence amounted to 37.5 and 30%, respectively, that of major amputation - to 67.5 and 24.1%, survival without major amputation - to 50 and 17.9%, respectively. Patients with LLCI kept on chronic haemodialysis belong to a group of high risk of limb loss and a lethal outcome within 2 years after angioplasty.

[Angiographic characteristics of the lesion, influencing the choice to perform either direct or indirect endovascular revascularization for critical ischaemia of the lower limbs].

AIM: to determine which angiographic characteristics of a lesion of lower limb arteries are independent predictors of the possibility to re-establish the direct blood flow along the angiosomic (in relation to the trophic defect) artery. MATERIAL AND METHODS: we carried out a retrospective analysis of angiograms of 192 patients with degree IV peripheral arterial disease according to A.V. Pokrovky's classification, with restored free blood flow to the foot at least along one femoral artery by means of balloon angioplasty. All patients were subdivided into two groups: the group of direct revascularization (84 patients) and the group of indirect revascularization (108 patients). The compared groups reliably did not differ by the clinical characteristics and the stage of the trophic lesion (male gender, prevalence of diabetes mellitus and mean age amounted to: 45%, 73% and 71 years versus 39%, 77% and 69 years, respectively). However, in the group of direct revascularization more frequently were encountered lesions of the toes (75% vs 55%, p = 0.005), while in the group of indirect revascularization prevailing were lesions of the heel region (7% vs 29%, p=0.0002). RESULTS: the statistical analysis showed that independent predictors for a possibility of performing direct revascularization were as follows: total occlusion of the angiosomic artery on the foot (risk ratio (95% CI) = 0.10 (0.03-0.31), p =0.0001), blind (without stump) occlusion in the site of the origin of the angiosomic artery on the crus or foot (risk ratio (95% CI)=0.41 (0.19-0.90, p=0.03), and total occlusion of the trifurcation of the popliteal artery (risk ratio (95% CI) = 028 (0.09-0.81), p=0.02). CONCLUSION: in the presence of the above enumerated angiographic characteristics of the lesions of lower limb arteries it is appropriate to initially consider a possibility of performing indirect revascularization.

[Angiographic assessment of the incidence rate of atypical variants of the development of crural and plantar arteries].

OBJECTIVE: assessing the incidence rate of atypical anatomical variants of the development of the popliteal artery and plantar arteries according to the findings of digital subtraction angiography. MATERIAL: Retrospective analysis of angiograms of 2,456 lower limbs in 1,305 patients. The character of the arterial lesion and the quality of the angiograms allowed of evaluating the anatomy of the popliteal artery and plantar arteries on a total of 1,609 extremities (65%). RESULTS: The incidence of atypical ramification of the popliteal artery amounted to 9%. Altered blood supply of the foot was observed in 7.6% of cases. The total incidence rate of atypical anatomical variants in men and women did not differ significantly. In the presence of a typical anatomical variant on one extremity, the prevalence of atypical blood supply of the other limb amounted to 16.3%. In the presence of an atypical anatomical variant on one limb, the incidence of atypical blood supply of the other amounted to 42%. In case of atypical blood supply of the foot on one limb, the incidence rate of the same-type abnormality on the other equalled 48%. CONCLUSION: In a typical variant of blood supply of one extremity, the probability of typical blood supply of the other amounted to 83 .7%, in an atypical variant decreasing to 58%. In case of atypical blood supply of one foot, one should suppose an analogous anatomical variant on the other foot in half of the cases.

Comparative analysis of remote results of transluminal balloon angioplasty in treatment of lower limb critical ischaemia in groups of patients with and without diabetes mellitus.

All the hitherto conducted studies aimed at determining the efficacy of transluminal balloon angioplasty (TLBAP) in patients presenting with lower limb critical ischaemia (LLCI) have either dealt with the whole population of the patients involved, including a large proportion therein of patients with simultaneously present diabetes mellitus (DM), or solely investigated a group of patients suffering exclusively from diabetic foot syndrome. There has virtually been no information about non-diabetic patients, thus casting reasonable doubts upon feasibility of subjecting them to TLBAP, especially in the situation wherein there does exist a surgical alternative. In order to elucidate the problem concerned, we performed a comparative analysis of the incidence rate of freedom from LLCI relapses following TLBAP in diabetic versus non-diabetic patients. Based on the findings obtained from this analysis, a conclusion was made that the remote results of TLBAP were statistically not considered to be different in the groups of diabetic patients and non-diabetic subjects within the time frame of a 12-month follow up period. For the joint group, the cumulative probability of freedom from LLCI relapses during one year amounted to 65%, which is comparable with the outcomes of distal bypass grafting operations.

[Transluminal balloon angioplasty as a method of choice in treatment of critical ischemia of lower extremities].

The authors analyzed results of treatment of 127 patients. A new direction in the endovascular treatment of critical ischemia of the lower extremities is substantiated on the basis of a combination of methods of subintimal and intraluminal angioplasty. For the first time all the patients with critical ischemia of lower extremities, and having no irreversible changes of the extremity requiring amputation at the level of the low leg or femur, must be considered as good candidates for translumbar balloon angioplasty.

[Peripheral angioplasty in patients with lower limb critical ischaemia after operations of femoropopliteal bypass grafting].

The study was aimed at retrospectively assessing the outcomes of peripheral angioplasty (PAP) in patients presenting with lower limb critical ischaemia (LLCI) after previously endured operations off emoropopliteal bypass grafting (FPBG). The PAP procedure was carried out in a total of nine patients diagnosed with LLCI meeting the criteria of the Trans-Atlantic Inter-Society Consensus (TASC), in whom repeat bypass grafting was recognized impossible owing to the absence of either shunting-fit veins or arterial segments suitable for anastomosing. Of these, eight patients had a femoropoplietal bypass graft implanted previously, and the remaining patient had a femoral-anterior-tibial one. In four cases, the patency of the shunts was preserved but all the three tibial arteries were occluded. Five patients displayed total occlusion of the shunts. In 80% of cases, the PAP procedure was performed in C and D types of morphology of the arterial lesion according to the TASC criteria. The PAP procedure was technically successful in eight (89%) patients, making it possibly to re-establish blood supply to the foot along at least one tibial artery. No clinically significant complications following PAP in the treated patients were observed. The average duration of follow up amounted to 9 months. Technically successful PAP was accompanied by clinical success in all the cases. During the follow-up period, one patient died from myocardial infarction with no signs of LLCI. A relapse of LLCI was observed in one (12.5%) patient. The obtained findings suggest that in the treated patients with LLCI after FPBG and impossibility of performing repeat bypass grafting, PAP proved to be a safe and efficient method of revascularization.

[Transluminal balloon angioplasty in treatment of lower limb critical ischaemia].

OBJECTIVE OF THE STUDY: To evaluate efficiency of transluminal balloon angioplasty (TLBAP) in treatment of lower limb critical ischaemia (LLCI). MATERIALS AND METHODS: Over the period from November 2004 to April 2008, we performed a total of 89 TLBAPs in eighty-two patients presenting with LLCI. The patients' age averagely amounted to 67.8 +/- 9.8 years. Fifty (61%) patients had an ischaemic ulcer on the foot, seventeen (20.7%) had gangrene, and fifteen (18.3%) patients suffered from ischaemic pain at rest. Forty-five (54.9%) patients suffered from diabetes mellitus, including thirty-three (40.2%) subjects with insulin dependent DM. Sixty (73.2%) patients were diagnosed as having coronary heart disease (CHD), sixty-five (79.3%) had arterial hypertension, twenty-five (30.5%) - cerebrovascular disease, and thirteen (15.9%) - chronic renal insufficiency. Six (7.3%) patients were on chronic haemodialysis. The distribution of the patients by the level of the lesion were as follows: iliac 4 (3.6%), femoropopliteal 55 (49.5%), crural artery 52 (46.8%) Type-C and type-D lesions (TASC) were encountered in 89.2% of cases. Occlusions were observed in 82% of all lesions of the crural artery. 42.2% of the patients were treated by means of subintimal angioplasty. Stenting was used in fourteen (7.3%) cases. RESULTS: The angiographic and clinical success of the procedure was achieved in seventy-five (91.5%) patients. No LLCI was observed either after one or three years in 79.4 and 52.9% of the patients, respectively.