[Case of endovenectomy and stenting with functioning arteriovenous fistula in extended post-thrombotic occlusion of deep veins]. / Sluchai éndovenéktomii i stentirovaniia s funktsioniruiushchei arteriovenoznoi fistuloi pri protiazhennoi posttromboticheskoi okkliuzii glubokikh ven.

We describe herein a case of surgical treatment of a 32-year-old female patient presenting with multilevel post-thrombotic occlusion of deep veins of the left lower limb. Laboratory study revealed high-risk hereditary thrombophilia (homozygous mutation of PAI-1, MTR, heterozygous mutation of MTHFR, MTRR, ITGA2). The first stage included endovenectomy from the common femoral vein with creation of an arteriovenous fistula between femoral vessels. An attempt of endovascular stenting of iliac veins was initially unsuccessful. After 3 months, the woman was rehospitalized to undergo successful endovascular operation with stenting of the iliac veins and common femoral artery on the background of the functioning arteriovenous fistula. The clinical outcome of the operation was good. Follow-up ultrasonographic examinations (ultrasound duplex scanning) were performed at 3, 6, 10 and 13 months after the second operation. The findings of ultrasound duplex scanning at 13 months showed that the stented segments of deep veins were freely patent, with the arteriovenous fistula functioning well. There were no signs of impairments of central haemodynamics, with significant regression of clinical symptoms. The total score by the Villalta scale as compared with the baseline values decreased from 13 to 5. Given the pattern of deep vein lesions, complexity of open and endovascular operations, and the presence of thrombophilia, we decided to abstain from disuniting the arteriovenous fistula. This case report demonstrates possibility, efficacy and safety of long functioning of an artificial arteriovenous fistula in a particular patient cohort.

[A case of successful endovascular treatment of a patient with chronic pelvic pain and recurrent varicocele]. / Sluchai uspeshnogo éndovaskuliarnogo lecheniia patsienta s khronicheskoi tazovoi bol'iu i retsidivom varikotsele.

Described in the article is a clinical case report regarding diagnosis and treatment of pelvic varicose veins in a 34-year-old male patient presenting with compressive stenosis of the left common iliac vein (May-Thurner syndrome). The man had developed clinical symptoms of the disease as varicocele when he was 17 years old. Multiple surgical interventions on the veins of the spermatic cord failed to result in significant success. The diagnosis was verified by means of ultrasound examination and contrast X-ray phlebography. The patient was subjected to balloon angioplasty and stenting of the compressive stenosis of the left common iliac vein. The endovascular treatment performed was followed by the patient's improved condition, confirmed by methods of instrumental diagnosis, as well as by regression of clinical symptomatology.

[First experience with hybrid operations for chronic obstruction of iliac-femoral segment veins in patients with post-thrombotic disease]. / Pervyi opyt gibridnykh operatsii pri khronicheskoi obstruktsii ven podvzdoshno-bedrennogo segmenta u patsientov s posttromboticheskoi bolezn'iu.

The present study was aimed at assessing initial results of hybrid operations in obstructive lesions of the iliac-femoral veins in patients with post-thrombotic disease (PTD). Hybrid operations [open endovenectomy from the common femoral vein (CFV) with creation of an arteriovenous fistula + stenting of iliac veins] were performed carried out in a total of eleven patients with PTD. Of these, there were 7 men and 4 women aged from 34 to 52 years (mean age - 42.8±7 years). All patients had severe-degree chronic venous insufficiency (CVI). The distribution of patients according to the CEAP classification was as follows: C4a - 2 patients, C4b - 4 patients, C5 - 4 subjects, C6 - 1 patient. The time having elapsed since a newly onset episode of acute iliac-femoral venous thrombosis varied from 2 to 12 years (averagely - 7.1±3.3 years). The degree of manifestation of PTD was determined by means of the Villalta-Pradoni scale before and 6 months after the operation. Instrumental methods of study included ultrasound duplex scanning (USDS), magnetic resonance and/or multispiral computed venography, and contrast-enhanced X-ray venography. The technical success of the procedure amounted to 91%. In one patient with occlusion of the common and external iliac veins we failed to perform recanalization and stenting. A further one patient developed in-stent and CFV thrombosis on the second postoperative day. An attempt of catheter thrombolysis turned out unsuccessful. There were no wound complications in the postoperative period. Neither was pulmonary artery thromboembolism registered. The dynamic control was carried out by means of USDS before discharge from hospital and at 1, 3 and 6 months after the intervention. The outcomes of hybrid operations after 6 months were followed up in five patients. Secondary patency rate of the stented iliac veins amounted to 100%. No relapses of trophic ulcers were observed. According to the Villalta-Prandoni scale the value of the median of the composite index decreased from 15 to 7 (p=0.012). The first experience with hybrid operations for obstructive lesions of veins of the iliac-femoral segment demonstrated their high efficacy and safety. Efficiency of the operation was confirmed by significant clinical improvement and good results of patency of the restored-repaired segments of veins.

[Endoprosthetic repair of abdominal aortic aneurysm complicated by rupture into the vena cava inferior with formation of an aortocaval fistula]. / Éndoprotezirovanie anevrizmy briushnoi aorty, oslozhnennoi razryvom v nizhniuiu poluiu venu s formirovaniem aorto-kaval'noi fistuly.

The article deals with is a case report of successful endovascular treatment of a patient with a saccular aneurysm of the infrarenal portion of the abdominal aorta complicated by its rupture into the inferior vena cava with formation of an aortocaval fistula. The patient underwent endoprosthetic repair of the abdominal aorta with the unilateral stent graft Endurant II 32x14-117 mm ("Medtronic") and cross-over femorofemoral bypass. The postoperative period was complicated by acute cardiac insufficiency and pulmonary oedema. After the appropriate intensive therapy lung oedema subsided, the events of cardiac insufficiency disappeared, and haemodynamics stabilized. According to the findings of the control multispiral computed tomography, the fistula does not function, there are no signs of the stent graft's dislocation or endoleak, with the cross-over femorofemoral bypass patent. The patient was discharged in a satisfactory condition.

[Hybrid operation for a posttraumatic saccular aneurysm of the aortic arch].

The article deals with a case report of successful hybrid surgical treatment of a patient presenting with a posttraumatic large false saccular aneurysm of the aortic arch with mediastinal displacement and compression of the left recurrent laryngeal nerve and trachea. The patient was subjected to a hybrid operation, i. e., bypass grafting of the brachiocephalic trunk and the left common carotid artery with a bifurcation prosthesis from the ascending aorta through sternotomy, carotid-vertebral and carotid-subclavian bypass grafting on the left in a combination with endoprosthetic repair of the aortic arch with the stent graft Valiant Thoracic 40 × 224 mm (VAMF 4040c200TE) manufactured by the Medtronic Company. The postoperative period was uneventful followed by rather rapid rehabilitation of the patient. One month after the operation, the clinical state improved considerably. His voice restored virtually completely, and breathlessness disappeared. According to the findings of MSCT angiography, the aneurysmatic cavity is thrombosed, with the stent graft showing no evidence of either dislocation or endoleak. The bifurcation bypass graft is functioning. According to the data of duplex scanning, the anastomoses established on the neck are patent.

[Stagewise surgical treatment in type III B chronic aortic dissection].

Presented herein is a clinical case report of successful surgical treatment (open and endovascular operation) of a patient with DeBakey type III B chronic aortic dissection. The diagnosis was verified by contrast-enhanced multispiral computed tomography (MSCT). The first stage consisted in operation of carotid-subclavian bypass grafting and aortomy with dissection of the internal membrane of the abdominal aorta, dividing the false and true channels. The second stage included endovascular prosthetic repair of the thoracic aorta with the Relay stent graft. The course of the postoperative period was uneventful. According to the MSCT findings 2 months after the intervention, the endograft was patent, with neither shift nor endoleack. The false channel along the descending thoracic aorta is thrombosed. The maximal diameter of the abdominal aorta does not exceed 4 cm. According to the findings of duplex scanning, the carotid-subclavian bypass is functioning. The patient's condition is satisfactory.

[Diagnosis and treatment of varicose disease of small pelvic veins].

The study was based on the findings of examination and treatment of fifty-four 19-to-55- year-old female patients (mean age 35.3 ± 7.3 years) presenting with varicosity of small pelvis veins. Of these, seventeen women with stenosis of the left renal vein were subjected to the following reconstructive operations on small pelvis veins: creating proximal ovarian-iliac anastomoses - 10 procedures, establishment of sapheno-ovarian anastomoses - 5 operations, one procedure of prosthetic repair of the left renal vein and one operation of transposition of the left renal vein. All interventions were completed with resection of the distal segments of the ovarian vein. A further 19 women with idiopathic reflux along the ovarian veins underwent uni- or bilateral embolization thereof, with multi-stage embolization of the branches of the internal iliac vein performed in one patient. The remaining eighteen endured the following interventions: unilateral resection of the left ovarian vein performed in twelve cases (3 endoscopic operations), bilateral resection in four cases (3 endoscopic resections). In seven cases the operations were supplemented with microphlebectomy of the varicosely altered perineal veins. Two patients underwent operations of crossectomy and resection of the pathologically altered internal pudendal vein. Five-year follow up showed that good-to-satisfactory results were obtained in 45 (83.3%) cases, with a disease relapse revealed in seven cases.

[First experience in stenting iliofemoral segment veins].

The authors share herein their first experience gained in stenting for stenosing and occlusive lesions of the iliac-femoral segment veins, reporting the outcomes of treating a total of thirteen patients subjected to balloon angioplasty and stenting of iliac veins for chronic venous obstruction. While treating non-thrombotic venous lesions, stenting was successfully performed in 100% of the patients concerned. Inpost-thrombotic lesions therapeutic outcomes were successful in 9 (75%) patients. No immediate postoperative complications were observed. The remote results were followed up in eleven out of the 13 patients. Patency within the terms up to 16 months amounted to 81.1%. Clinical improvement was noted in 12 (92.3%) patients. According to the VCSS scale, there was a reliable decrease in the intensity of chronic venous insufficiency manifestations along all parameters. The integral index decreased from 6.56+/-0.71 to 4.45+/-0.65 (t=3.82, p<0.002). The malleolar volume decreased from 275.3+/-6.7 to 241.6+/-6.1mm (t=12.3, p<0.001). Hence, angioplasty and stent-grafting of iliofemoral veins turned out to be a minimally invasive, safe, and highly efficient therapeutic modality. The efficacy of the procedure was confirmed by a considerable improvement of the limb's condition and good remote results concerning patency of the reconstructed segments of the venous bed. Endovascular methods may be considered as a promising modality of treatment for this patient cohort.

[Surgical and endovascular treatment of floating thromboses in the system of the inferior vena cava].

In order to work out the indications for surgical and endovascular treatment of floating thromboses in the system of the inferior vena cava (IVC) and to evaluate the therapeutic outcomes obtained we examined a total of one hundred and forty-five 17-to-85-year-old patients presenting with acute thrombosis in the system of the IVC. Of these, floating thromboses were revealed in ninety-five patients. The most frequently encountered localization of the floating thrombus was the common femoral vein (CFV). In 77 patients, thrombosis originatedfrom the femoral vein (FV), and in 12 instances -from the saphenofemoral junction. The signs of pulmonary thromboembolism (PTE) were diagnosed in 22 cases. Instrumental studies included ultrasonographic duplex scanning (USDS), roentgenopaque and computer-assisted phlebography, and perfusion-mediated scintigraphy of the lungs. Thrombectomy from the common iliac vein (CIV), external iliac vein (EIV) and common femoral vein (CFV) with resection of the femoral vein was performed in forty-seven patients; of these, the procedure was combined with establishing a temporal proximal arteriovenous fistula (AVF) in sixteen subjects. The femoral vein was resected in nineteen instances. Thrombectomy form the IVC with the help of the "TREKS" device was carried out in six patients. Cava filters were implanted in a total of eighty-four patients. Of these, ten devices were intended and had to be 3 left for permanent implantation, with the remaining seventy-four patients having received retrievable ones. Rethromboses in the early postoperative period were observed to occur in four patients. The patients with the AVFs applied had no thromboses. PTE occurred in four patients, with one lethal outcome. Another patient died due to myocardial infarction. Temporary cava filters were successfully retrieved in sixty-eight patients within the terms from 10 to 56 postoperative days long-term results up to 2 years were followed up for thirty-eight patients, with good outcomes noted in twenty-six cases, satisfactory in ten, and poor results seen in two patients. An active therapeutic policy pursued in management of floating embolus-hazardous thromboses is the only efficient measure making it possible to reliably prevent the development of both PTE and post-thrombotic disease.

[Angioplasty and stenting of carotid arteries in patients with high surgical risk].

The authors carried out carotid angioplasty and stenting (CAS) in forty-six patients (with a total of 48 interventions performed). Of these, forty-two (91.3%) patients were found to belong to a high-surgical-risk group; The patients years (mean age - 62.1 +/- 8.2 years). Thirty-six patients were found to have symptomatic lesions of the internal carotid arteries (ICAs) >70%, and ten had asymptomatic stenoses >80%. Twenty-three (50%) patients were diagnosed with grade II cerebrovascular insufficiency (CVI) (transitory ischaemic attacks). Amongst the most frequently encountered accompanying pathologies were various-severity CADs in forty (95.2%) patients, and arterial hypertension in thirty-eight (90.4%). The cerebral blood flow state during CAS interventions was controlled by means of transcranial Doppler ultrasonography in sixteen patients. In twelve patients, the main stage of the intervention was performed under control of ultrasonographic duplex scanning (USDS). The technical success of the operation was achieved in forty-four (95.7%) cases. Failures were primarily caused by impossibility of passing the guidewire catheter in type 3 aortic arch in two patients. Twenty-six (56.5%) patients developed bradycardia and hypotension after CAS. No haemodynamically significant restenoses following CAS within the follow-up terms from 2 to 12 months were observed in twenty-two patients. The article also contains a brief comparative analysis of multicenter randomized studies on the CAS-related problem. In conclusion, the authors note safety and high efficiency of CAS, considering this intervention an alternative to carotid endarterectomy in patients with elevated surgical risk. A USDS-controlled operation significantly broadens the possibilities of the method concerned.

[Combined bolus magnetic resonance angiography and two-dimensional time-of-flight magnetic resonance angiography in patients with occlusive diseases of lower limb arteries].

AIM: The purpose of the work was to assess the diagnostic significance of combined bolus magnetic resonance angiography (MRA) and two-dimensional time-of-flight MRA of lower limb arteries as compared to radioangiography in patients with occlusive diseases of lower limb arteries. MATERIAL AND METHODS: Twenty-six patients with the symptoms of lower limb ischemia of varying severity were provided bolus MRA with prolonged manual injection of contrast substance and transposition of the MR-tomograph table. Additionally, all the patients underwent two-dimensional time-of-flight (2D TOF) MRA of the leg arteries. RESULTS: The statistic processing of bolus MSA for visualization of the pelvic segment has demonstrated its high sensitivity and specificity (97.74% and 92.31% respectively). On visualization of the femoral artery segment the sensitivity of this modality accounted for 97.57%, the specificity for 94.57%. In patients with severe ischemia, visualization of the leg arteries was difficult. Consequently, the specificity of the modality accounted for 44.58%. However, when this technique was combined with two-dimensional time-of-flight MRA of the leg arteries, the sensitivity and specificity of the modality reached 96.38% and 91.92% respectively. CONCLUSION: Bolus MRA of lower limb arteries is marked by the high sensitivity and specificity for visualization of the arteries of the iliac and femoral segments. To visualize the leg arteries in patients with severe forms of lower limb ischemia, this modality should be supplemented by two-dimensional time-of-flight MRA.

[The reperfusion therapy of ischemic stroke in the inter regional clinical-diagnostic center of Kasan].

The high-tech methods of diagnostics and treatment of patients with ischemic stroke during the therapeutic window have been introduced in the Inter regional clinical-diagnostic center of Kasan. These are systemic intravenous pharmacological thrombolysis, intra-arterial selective pharmacological thrombolysis, balloon angioplasty with simultaneous stenting of an occlusive vessel. The results obtained indicate that the implication of these techniques allows to increase the effectiveness of treatment of patients with acute cerebral ischemia provided minimization of the preperfusion period, individual approach in the choice of a method of thrombolysis, assessment of the character of occlusive process and specifics of the lesion on MRI, use of neuroprotection.

[Contrast-enhanced MRA of abdomen and lower limbs arteries: artifacts and pitfalls]. / Oshibki i artefakty pri provedenii kontrastnoi magnitno-rezonansnoi angiografii abdominal'nogo otdela aorty i arterii nizhnykh konechnostei.

The purpose of the work was the analysis of the most widespread diagnostic mistakes in connection with the technical artifacts arising at performing contrast-enhanced MR-angiography of abdomen and lower limbs arteries.