[Use of extracorporeal membrane oxygenation for pulmonary haemorrhage after pulmonary endarterectomy]. / Primenenie ékstrakorporal'noi membrannoi oksigenatsii pri legochnom krovotechenii posle legochnoi éndarteréktomii.

Pulmonary haemorrhage is one of the most severe complications of pulmonary endarterectomy. To the most effective methods of combating this potentially fatal complication belongs extracorporeal membrane oxygenation (ECMO). In this article we describe a clinical case report regarding intraoperative use of central veno-arterial ECMO for pulmonary haemorrhage following thromboendarterectomy from the pulmonary arteries. According to the data of some authors, long-term ECMO support (for more than 4 days) may lead to such severe consequences as rethrombosis of pulmonary arteries and impairment of cerebral circulation. In our case we managed to avoid such complications, taking into consideration that the duration of ECMO amounted to 21 days. Resulting from the carried out comprehensive therapeutic measures by the time of discharge from hospital, a significant decrease in pulmonary artery pressure was achieved, with events of residual pulmonary hypertension.

[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.

[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.

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.

[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.

[Experience in surgical management of posttraumatic arteriovenous aneurysms of the aortorenal zone].

Presented herein are two clinical case reports concerning surgical management of posttraumatic arteriovenous aneurysms of the juxtarenal portion of the aorta and left renal vein, demonstrating the informative value of multispiral computed angiography in diagnosis of the pathology involved. Two patients presenting with a stab-and-lacerated wound of the abdominal cavity and subjected to comprehensive examination were found to have an arteriovenous anastomosis between the aorta and left renal vein with the formation of an up to 35-mm aneurysm in one case, and an arteriovenous anastomosis between the left renal artery and left renal vein with the formation of a pseudoaneurysm sized up to 30 mm in the other. Both patients had a clinical picture of cardiopulmonary insufficiency induced by overloading of the right portions of the heart. Both pathologies were treated surgically in the scope of removing the arteriovenous anastomosis and aneurysm of the juxtarenal portion of the abdominal aorta and left renal artery. The postoperative period showed nothing to report and turned out uneventful, with the patients being discharged from the clinic in a satisfactory condition with good laboratory and haemodynamic parameters.

[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.

[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.