[Extended lesion of the internal carotid artery: carotid autotransplantation, creation of a neobifurcation or prosthetic repair?] / Protiazhennoe porazhenie vnutrennei sonnoi arterii: karotidnaia autotransplantatsiia, formirovanie novoi bifurkatsii ili protezirovanie?

AIM: The aim of our investigation was to analyse the results of autotransplantation, creation of a neobifurcation or prosthetic repair of the internal carotid artery during the in-hospital and long-term follow-up periods. PATIENTS AND METHODS: The study included a total of 241 patients presenting with and treated for extended atherosclerotic lesions of the internal carotid artery from 2016 to 2019. The patients were divided into three groups depending on the surgical modality employed: group 1 - autotransplantation of the internal carotid artery (27.8%, n=67), group 2 - creation of a neobifurcation (55.2%, n=133), and group 3 - prosthetic repair of the internal carotid artery (17.0%, n=41). The duration of the postoperative follow-up period amounted to 24.8±11.9 months. The outcome measures selected were as follows: all-cause mortality, myocardial infarction, ischaemic stroke, haemodynamically significant restenosis, and a composite endpoint (death + myocardial infarction + ischaemic stroke + haemodynamically significant restenosis). RESULTS: During the in-hospital postoperative period we registered 1 (2.4%) ischaemic stroke in the group of prosthetic repair, with no significant inter-group difference revealed (p=0.08). In the remote period of follow-up, no statistical differences were revealed for the following outcome measures: all-cause mortality (group 1: 7.5%, n=5; group 2: 10.5%, n=14; group 3: 14.6%, n=6; p=0.49); cardiovascular-related death (group 1: 4.5%, n=3; group 2: 6.7%, n=9; group 3: 12.2%, n=5; p=0.31); myocardial infarction (group 1: 1.5%, n=1; group 2: 3%, n=4; group 3: 4.9%, n=2; p=0.59). However, the patients in the group of prosthetic repair of the internal carotid artery were found to have the highest incidence rates of ischaemic stroke (group 1: 3%, n=2; group 2: 3%, n=4; group 3: 14.6%, n=6; p1-2=0.1; p1-3=0.02; p2-3=0.008), haemodynamically significant restenosis (group 1: 0%, n=0; group 2: 0%, n=0; group 3: 14.6 %, n=6; p1-2>0.99; p1-3=0.000; p2-3=0.000), and higher values of the composite endpoint (group 1: 12 %, n=8; group 2: 16.5%, n=22, group 3: 48.8%, n=20; p1-2>0.99; p1-3=0.000; p2-3=0.000). CONCLUSION: Prosthetic repair of the internal carotid artery for an extended atherosclerotic lesion is a less preferable method compared with autotransplantation and creation of a neobifurcation, as evidenced by the highest incidence rates of ischaemic stroke, haemodynamically significant restenosis, and higher values of the composite endpoint in the remote period of follow up.

[Treatment of a patient with acute thoracoabdominal aortic dissection complicated by haemothorax]. / Lechenie patsienta s ostroi dissektsiei torakoabdominal'nogo otdela aorty, oslozhnennoi gemotoraksom.

Total left-sided haemothorax is a rare and severe complication of acute DeBakey type III aortic dissection. The primary aim of treatment is immediate arrest of haemorrhage and stabilization of the haemodynamic status of the patient. Endovascular isolation of the ruptured thoracic portion of the aorta using a stent graft (TEVAR) has recently become the 'gold standard' in treatment of acute, rupture-complicated aortic dissections of this localization. Described in the article is a clinical case report concerning successful endovascular treatment of a seriously ill patient with dissection of the thoracoabdominal portion of the aorta, rupture and massive haemorrhage into the left pleural cavity. The patient underwent endoprosthetic repair of the descending aorta in the setting of a hybrid operating room under local anaesthesia, followed by drainage of the left pleural cavity. The postoperative period was uneventful with no complications. The patient was discharged in a satisfactory condition on day 10 after the emergency surgical intervention. An important advantage of TEVAR for aortic ruptures is a minimally invasive nature of the procedure, consisting in no need to perform either sternothoracotomy or to connect a heart-lung machine, thus decreasing surgical wound, reducing the risk of perioperative life-threatening haemorrhage, and contributing to early activation of the patient.

[Carotid endarterectomy in a patient with bilateral restenosis of stents in internal carotid arteries]. / Karotidnaia éndarteréktomiia u bol'nogo s dvustoronnim restenozom stentov vo vnutrennikh sonnykh arteriiakh.

The article deals with the results of surgical treatment of a male patient presenting with bilateral restenosis of stents in the internal carotid arteries 11 years after carotid angioplasty with stenting. Described herein are literature reports reflecting the state of the art of the problem, scarcity of studies, as well as some important issues still unresolved. Defined are the main indications for and contraindications to performing this type of reconstruction. The main stages of the operation are demonstrated. This is followed by describing a method of intraoperative protection of the brain, including invasive measurement of retrograde pressure. Besides, the most optimal terms of carrying out the second stage of treatment were determined, eventually demonstrating efficacy and safety of carotid endarterectomy for correction of this condition.

[Hibrid surgical treatment of an aortic arch aneurysm]. / Gibridnoe khirurgicheskoe lechenie anevrizmy dugi aorty.

Presented in the article is a clinical case report regarding hybrid surgical management of a saccular aneurysm of the aortic arch: simultaneous right-left-carotid-left-subclavian bypass grafting and endovascular isolation of the aneurysm. Taking into consideration the findings of multislice computed tomography-aortography (MSCT aortography) prior to surgery, the anatomical location of the aneurysm with the involvement of the ostium of the left subclavian artery, close location of the proximal branches of the aortic arch at an acute angle relative to each other required performing simultaneous debranching in order to enlarge the proximal zone of fixation of a stent graft at the level of the brachiocephalic trunk (BCT). The postoperative period proved uneventful, with as rapid rehabilitation as possible. From our own experience, with this one being not the first similar operation performed in the Centre, it may be supposed that carrying out simultaneous hybrid interventions in treatment of aneurysms of the aortic arch with the use of different variants of switching its branches may decrease the frequency of postoperative complications for patients of high surgical risk, reduce the length of hospital stay and, consequently, economic expenditures for treatment.

[Surgical treatment of chronic thromboembolic pulmonary hypertension]. / Khirurgicheskoe lechenie khronicheskoi tromboémbolicheskoi legochnoi gipertenzii.

Analysed herein are the results of pulmonary endarterectomy (PEA) performed in a total of 169 patients presenting with chronic thromboembolic pulmonary hypertension (CTEPH) at the National Medical Research Centre named after Academician E.N. Meshalkin over the period from 2004 to 2014. Pulmonary endarterectomy was carried out according to the standard technique in the conditions of assisted circulation with the use of hypothermia and circulatory arrest. The duration of follow up of patients after surgical treatment amounted to 10 years. During the in-hospital period (30 postoperative days) and in the remote period after the intervention (averagely amounting to 7.7±2.3 years), the following parameters were evaluated: the clinical status of the patients by means of the SF-36 Quality of Life Questionnaire, the 6-minute walk test, as well as the findings of instrumental methods of study, namely, transthoracic echocardiography, multispiral computed angiography of the pulmonary artery (PA), catheterization of the right portions of the heart, perfusion scintigraphy of the lungs. The obtained results demonstrated that removal of thromboembolic obstruction of the PA was followed by significant improvement of intracardiac haemodynamics, volumetric-and-functional parameters of the right portions of the heart, pulmonary perfusion, accompanied by reverse remodelling of the right heart and lesser circulation (LC), which was manifested by a decrease in the following parameters: systolic and mean blood pressure in the PA, resistance of the LC vessels, total value of perfusion deficiency of the lung, as well as by a decrease in the dimensions of the right chambers of the heart and the diameter of the pulmonary trunk. Normalization of intracardiac haemodynamics resulted in improvement of the clinical and functional state of the patients both in the immediate and remote periods, which was confirmed by elevation of the scores on all scales of the SF-36 Quality of Life Questionnaire, a 2.25-fold increase in the distance walked over a span of 6 minutes, and a decrease in the functional class of chronic heart failure according to the NYHA classification. The obtained findings suggest high efficacy of performing PEA in patients with CTEPH, thus making it possible not only to prolong the lifespan of the patients but to increase their quality of life.

[Staged treatment of a multilevel lesion of brachiocephalic arteries in combination with coronary and valvular pathology of the heart]. / Étapnoe lechenie mnogourovnevogo porazheniia brakhiotsefal'nykh arterii v sochetanii s koronarnoi i klapannoi patologiei serdtsa.

Prevention of neurological complications in cardiosurgical and reconstructive vascular surgery is one of the priority tasks of preserving ability to work and decreasing invalidization of patients in the postoperative period. Presented in the article is a clinical case report regarding multiple-stage treatment of a female patient with a combined aortic defect, coronary pathology, and a multilevel bilateral lesion of the brachiocephalic arteries. The first stage consisted in performing a hybrid operation, i. e., carotid endarterectomy from the right internal carotid artery and stenting of the ostium of the right common carotid artery (CCA). The second stage involved balloon angioplasty with stenting of the left CCA, and the third stage was prosthetic repair of the aortic valve by a mechanical prosthesis with simultaneous coronary artery bypass grafting. The woman was discharged in a satisfactory condition. Described in details is the technique of performing the hybrid vascular operation, followed by substantiating the stagewise nature of surgical interventions. The policy chosen demonstrates effective and safe correction of haemodynamically significant tandem stenoses of brachiocephalic arteries, without neurological complications during treatment of patients with cardiological pathology.

Oxygen provision of the brain at various stages of operation in patients with chronic pulmonary artery thromboembolism.

The authors studied cerebral oxygen supply by means of cerebral oximetry in patients presenting with chronic pulmonary artery thromboembolism (PATE) at various stages of operation. The study was aimed at assessing cerebral oxygen supply while carrying out surgical treatment in patients with chronic PATE on the background of various methods of perfusion. Thromboendarterectomy (TEA) from the pulmonary artery with the use of circulatory arrest and craniocerebral hypothermia is accompanied by more pronounced impairment of oxygen supply of the brain with a decrease in the cerebral oxygenation indices by more than 30% from the baseline values. These alterations promote increased risk for the development of neurological complications in the early postoperative period. Using the technique of antegrade cerebral perfusion ensures a minimum decrease of cerebral oxygenation during TEA and contributes to a reduction of the risk for the development of neurological complications.

[Five-year results of surgical management of patients with chronic post-embolic pulmonary hypertension].

Over the period from 2004 to 2013, a total of 146 patients presenting with chronic post-embolic pulmonary hypertension (CPEPH) underwent the operation of pulmonary thromboendarterectomy (TEE) at the Centre for Surgery of the Aorta, Coronary and Peripheral Arteries. The operation was carried out according to the conventional technique with the use of hypothermia and circulatory arrest. The dynamics of the clinical and functional state was assessed by analysing the following parameters: 6-minute walk test, mean pulmonary artery pressure, and resistance of lesser circulation vessels (according to the data of catheterization of the right parts of the heart), as well as the diameter of the pulmonary artery trunk (by data of MSCT angiography of the pulmonary artery). The distance of the 6-minute walk was indicative of the corresponding functional class of chronic heart failure according to the NYHA classification. The obtained results showed that pulmonary TEE eliminates the main cause of pulmonary hypertension - thrombotic obstruction of pulmonary arteries, thus leading to normalization of the lesser circulation, a decrease in the load on the right ventricle and, consequently, to considerable improvement of the functional state of patients. Performing the operation of TEE from PA branches leads to improved clinical and functional condition of patients with CPEPH both at the hospital stage and further in the remote period after surgery, which is confirmed by a more than 2.5-fold increase of the 6-minute walk distance and a decrease of CHF functional class (by NYHA). A decrease of vascular resistance of the lesser circulation from 539.66±120.59 din×s×cm(-5) before surgery to 101.39±89.20 din×s×cm(-5) in the remote period is indicative of remodelling of the right ventricle and distal arterioles of the lesser circulation. A decrease of the PA trunk diameter from 35.10±5.25 mm before the operation to 30.30±8.65 mm in the remote period is suggestive of structural rearrangement of the pulmonary arterial bed with a tendency towards normalization and of efficacy of surgical treatment performed.

[Cerebral oxygen supply in patients with chronic pulmonary artery embolism].

Aim of this study was to assess brain oxygen supply in patients with chronic pulmonary embolism (CPE) for elucidation of factors of risk of neurological complications in early postoperative period. We examined 34 patients with diagnosis of CPE. Mean duration of the disease was 3 (1.4-4.2) years. Data on baseline cerebral oxygenation, monitoring of brain oxygen during various stages of surgery, and level of cerebral oxygen supply in immediate postoperative period are presented. More than 40% lowering from initial values of parameters of cerebral oxygenation during circulatory arrest substantially increases risk of development of neurological complications in early postoperative period.

Hybrid technology in treatment of severe combined pathology.

The present report describes a clinical case concerning a two-stage hybrid operative intervention in a patient presenting with an aortic arch aneurysm associated with coronary artery disease. The first stage consisted in performing mammary coronary artery bypass grafting of the anterior descending artery, coronary artery bypass grafting of the right coronary artery, endoventricular plasty of the left ventricle according to the Dor technique, switching over of the brachiocephalic arteries to the ascending portion of the aorta with the vascular multiple-branch prosthesis Intergard. The second stage consisted in endoprosthetics of the aortic arch with a stent graft. The patient concerned belongs to a high-risk group for the development of postoperative complications. Endovascular techniques in the pathology involved may be an alternative to the conventional surgical treatment, since there is no necessity to use extracorporeal haemocirculation or deep hypothermal circulatory arrest. It is necessary to analyse the remote results, to work out the indications for the interventions concerned, especially in elderly and aged patients presenting with a variety of accompanying pathology.

[Treatment of reperfusion renal lesion after surgical management of chronic post-embolic pulmonary hypertension by means of extracorporeal membrane oxygenation (ECMO)].

Thromboendarterectomy from the branches of the pulmonary artery is a conventionally accepted approach to treatment for pulmonary hypertension in chronic pulmonary embolism. A frequently encountered complication associated with this operation is the development in the postoperative period of the reperfusion syndrome as a potential cause of fatal respiratory failure. Taking into consideration that the reperfusion syndrome is a reversible process, waiting measures of support may save the patient's life. The present article deals with a case report concerning successive surgical management of a female patient suffering from chronic recurrent pulmonary thromboembolism accompanied by high pulmonary hypertension complicated by severe respiratory insufficiency in the early postoperative period, thus requiring long-term use of veno-venous extracorporeal membrane oxygenation (ECMO). The clinical case described in the article shows that veno-venous ECMO may be employed to save patients presenting with reperfusion syndrome following thromboendarterectomy from the branches of the pulmonary artery. The method of connecting ECMO namely in the veno-venous option in this particular case was determined by fact that the patient had no cardiac insufficiency. Numerous studies conducted hitherto have also confirmed that using ECMO in the veno-venous variant is accompanied and followed by a lower incidence rate of complications as compared with that of the veno-arterial variant. The results of our case report strongly suggest that timely use of ECMO in the composition of rehabilitation measures during restoration of the compromised lungs may become an effective strategy aimed at improving survival of patients after successful thromboendarterectomy from the pulmonary artery branches.

[Dynamics of lung perfusion after pulmonary thromboendarterectomy in patients with chronic postembolic pulmonary hypertension].

Perfusion scintigraphy of the lungs is used as screening in order to confirm thrombormbolic genesis of pulmonary hypertension. Meanwhile, perfusion scintigraphy is a non-invasive and objective method of assessing haemocirculation in the pulmonary tissue. Using the quantitative method of calculation of the perfusion deficit, one may judge about efficiency of the treatment performed and to assess the dynamics of the state of the micro- circulatory bed of the lung. We examined a total of 53 patients presenting with chronic postembolic pulmonary hypertension, who underwent pulmonary thromboendarterectomy. Pulmonary tissue blood flow was assessed by means of perfusion scintigraphy prior to operation, and in the early postoperative (3 weeks after operation) and remote (6 months and more) periods. Analysing the values of perfusion deficit in patients depending on the pulmonary hypertension degree we revealed close correlation dependence between the perfusion deficit and pulmonary hypertension, i. e., increased pressure in the pulmonary artery was accompanied by a decreased defect of lung perfusion according to the findings of perfusion scintigraphy. Analyzing the findings of perfusion scintigraphy in patients presenting with chronic postembolic pulmonary hypertension prior to surgery, in the immediate and remote postoperative periods in all groups showed a statistically significant decrease in the perfusion deficit. It was demonstrated that the method of perfusion pulmonary scintigraphy reliably reflects the alterations in the pulmonary tissue perfusion after lung pulmonary thromboendarterectomy, thereby reflecting efficiency of surgical treatment. With the initially pronounces pulmonary hypertension, improvement of lung perfusion obtained at the hospital stage also continues in the remote period.

[Surgical correction of visceral-organ and lower-limb malperfusion syndrome in patients with aortic dissection].

The article deals with the experience gained in treatment of 28 patients presenting with type I and III aortic dissection (according to DeBakey) complicated by visceral-organ and lower-limb malperfusion syndrome. Those presenting with type I aortic dissection were subjected to reconstructive operations on the aortic arch as the first stage. The events of renal insufficiency and abdominal ischaemia were coped with and relieved using by-passing operations on the visceral branches - iliac-renal, ilac-renal-mesenteric by-pass grafting. In two cases in acute ischaemia of the lower limbs we performed aorto-bi-iliac prosthetic repair. In one case we revealed thrombosis of the iliac-renal by-pass, also performing iliac-renal re-do shunting. No other complications during surgical interventions were observed, neither were any lethal outcomes encountered. Bypassing operations on the visceral and renal arteries in patients with aortic dissection make it possible to eliminate both abdominal and renal ischaemia as well as malperfusion of lower extremities.

[Hybrid operative intervention for DeBakey type III aortic dissection with the relay stent graft].

Determining the exact incidence of aortic dissection is highly conjectural because many cases of the disease remain undiagnosed. According to the autopsy findings, the incidence rate of the pathology concerned varies within the range from 0.2 to 0.8%. In clinical practice, aortic dissection is the cause of sudden death in 1.1% of the patients involved. However, aortic dissection should by no means be considered a rare disease. According to Borst et ah, ruptures in thoracic-portion aortic dissections are encountered 2-3 times more often than tears occurring in abdominal aortic aneurysms. The prognosis for patients presenting with a chronic aortic dissection is unfavourable. The commonest complications of the natural course of the disease include the development of a secondary dissection, formation of an aneurysm, progression of aortic regurgitation and circulatory insufficiency, occlusion of the aortic branches, and a late aortic rupture being the immediate cause of death in 30% of patients suffering from chronic dissection. With the recent advent of stent grafts, there appeared a possibility in the majority of cases involving a chronic type B dissection by the Stanford classification to substantially avoid an otherwise inevitably traumatic and typically prolonged reconstructive operation. Unfortunately, in some patients, owing to anatomical peculiarities, it is not always possible to deploy an endograft, thus requiring a major surgical intervention to perform instead. The authors describe herein a case of endovascular prosthetic reconstruction of the aortic arch and the descending portion in a patient who was found to have a type III aortic dissection according to the DeBakey classification and treated with the Relay stent graft.

[Hybrid operative interventions in multilevel lesions of the brachiocephalic arteries in patients with cerebrovascular insufficiency].

The authors share herein their experience with hybrid surgical interventions for multilevel lesions of the brachiocephalic arteries (stenting and an open operation) in a total of eleven patients presenting with cerebrovascular insufficiency. Our first experience gained in performing hybrid operations confirmed a possibility of correcting tandem stenoses of the brachiocephalic arteries from the standard approach to the common carotid artery bifurcation. No intraoperative complications were encountered. Hybrid interventions made it possible to reliably correct multiple arterial stenoses, necessitating neither additional bypass grafting nor prosthetic repair.

[Endovascular prosthetic repair of the infrarenal portion of the aorta with the aorfix bifurcated stent graft].

Reconstructive surgery or abdominal aortic aneurysms (AAA) currently remains one of the most complicated and dramatic divisions of the present-day vascular surgery. On the one hand, this is accounted for by the increased prevalence of the disease due to both improved diagnosis and a prolonged life span of the population, and hence more frequent occurrence ofabdominal aortic aneurysms. On the other hand, the conventional surgical treatment is known to be associated with a severe surgical injury and impairments of haemostasis on the background of a wide variety of accompanying diseases in patients who typically appear to be elderly and aged, thus sending us in search of less traumatic and more sparing techniques, with the endovascular aortic prosthetic repair being an encouraging example thereof (1-4). The recent advent of stent grafts has made it possible in the majority of cases to substantially avoid an otherwise inevitably traumatic and prolonged abdominal operation, which is particularly important in elderly and aged patients presenting with a severe concomitant pathology. The authors report herein a clinicalcase of successful endovascular prosthetic reconstruction of the infrarenal portion of the abdominal aortic aneurysm by means of the Aorfix bifurcated stent graft in a 78-year-old female patient.