Scintigraphic Imaging of Inflammation in the Aortic Wall Using 99mTc-Pyrophosphate.

The aim of this study was to develop and test a technique for scintigraphic examination of the thoracic aorta, which allows for visualizing foci of inflammation. Materials and Methods: The study included 15 patients (median age - 61 [47; 73] years) with aortic dilatation more than 45 mm and thoracic aortic aneurysm who were candidates for surgical treatment. All patients underwent a chest scintigraphy with 99mTc-pyrophosphate 48 h before surgery to identify foci of inflammation in the aortic wall. The new technique included intravenous administration of 370 MBq of a radiopharmaceutical (RP), registration of scintigrams at 3 and 6 h after injection of RP in a tomographic mode combined with X-ray computed tomography. After the image reconstruction, subtraction of the later scintigrams from the early ones was performed, followed by analysis of the final images. The results of scintigraphy were compared with the histological data obtained from intraoperative samples of resected aorta. Results: According to the results of this novel scintigraphic technique, artifacts from the radioactivity of the vascular blood pool were eliminated and pathological RP uptake was identified in 5 (33.3±1.5%) out of 15 examined patients. The "focus/vessel lumen" ratio averaged at 1.47 [1.30; 1.48]. Histological examination of resected aorta samples confirmed the presence of chronic inflammation in 4 (26.7±1.3%) out of 15 patients. Parameters of diagnostic efficiency were: sensitivity - 100%, specificity - 91%, diagnostic accuracy - 93%. Conclusion: The method of scintigraphic diagnostics of inflammatory processes in the aorta using 99mTc-pyrophosphate, supplemented by subtraction of the late from the early images, makes it possible to eliminate artifacts from the radioactivity of the aortic blood pool and to reveal the pathological RP accumulation indicating the areas of inflammation in the aortic wall.

[Predictors of early adverse events after the frozen elephant trunk procedure]. / Prediktory rannikh negativnykh klinicheskikh sobytii posle operatsii 'zamorozhennyi khobot slona'.

AIM: The aim of this study was to identify predictors of adverse events after the frozen elephant trunk procedure in the early postoperative period. PATIENTS AND METHODS: Between March 2012 and March 2020, a total of 273 patients were operated on for aortic pathology. A retrospective analysis aimed at identifying probable predictors was performed on 83 patients who underwent the FET procedure. Uni- and multivariate logistic regression was used to identify predictors of such adverse events as postoperative delirium, respiratory failure, acute kidney injury, and in-hospital mortality. RESULTS: According to the findings of the optimal multivariate regression model, separate reimplantation of the supra-aortic branches was a significant predictor of postoperative delirium (OR 10.41; 95% CI 1.1-35.45; p=0.05); significant risk factors for prolonged respiratory support were the duration of surgery (OR 1.02; 95% CI 1.01-1.03; p<0.001) and postoperative acute renal injury (OR 8.72; 95% CI 1.67-57.38; p=0.014). Independent risk factors for postoperative renal injury turned out to be the true lumen diameter of the descending aorta (OR 1.3; 95% CI 1.1-1.72; p=0.015) and chronic type A aortic dissection (OR 44.07; 95% CI 3.29-2354.8; p=0.014); statistically significant risk factors for in-hospital mortality were multiple organ dysfunction syndrome (OR 14.34; 95% CI 1.69-155.48; p=0.016) and coronary artery stenosis (OR 3.36; 95% CI 1.19-13.26; p=0.042). CONCLUSION: Separate reimplantation of the supra-aortic branches, duration of surgery, acute kidney injury, chronic aortic dissection, multiple organ dysfunction syndrome, true lumen diameter of the descending aorta, coronary atherosclerosis and haemoglobin level were statistically significant predictors of adverse events in the early postoperative period.

[Role of intraoperative flowmetric assessment of coronary artery bypass grafts established on-pump]. / Rol' floumetricheskoi otsenki koronarnykh shuntov na ostanovlennom serdtse.

AIM: This study was undertaken to evaluate the efficacy of three-stage measurement of the transit-time flow through coronary bypass grafts with the help of flowmetry for early verification of technical errors during on-pump coronary artery bypass graft surgery. PATIENTS AND METHODS: We performed an intraoperative analysis of 214 bypass grafts with the help of three-stage flowmetry. The first stage of measuring was performed on-pump with and without the proximal loop test, the second stage of measurement was performed after weaning the patient off the heart-lung machine, and the third stage of measurement was carried out after heparin inactivation prior to chest wound closure. RESULTS: Amongst the 214 transplants regarded as functioning, intraoperative flowmetry revealed insufficient blood flow in 9 (4.2%) cases. Technical surgical errors were confirmed in these shunts during revision thereof. In 6 (2.8%) of the 9 such grafts we detected non-optimal parameters of flowmetry during the first measurement (while the heart was stopped); of these, in 5 (2.3%) cases non-optimal blood flow was verified with the use of the proximal loop test on the target coronary artery and in 1 (0.47%) case without it. In another one (0.47%) of the nine such transplants, inadequate blood flow was revealed during the second measurement, which confirmed technical errors in proximal anastomoses. In a further 2 (0.93%) of the 9 such transplants we observed low parameters of blood flow during the third measurement, which was related to kinking of the shunts due to their excessive length. All surgical errors were corrected immediately at the stage of verification thereof. CONCLUSION: The strategy of three-stage assessment of flowmetry makes it possible to ensure and confirm adequate functionality of coronary artery bypass grafts at all stages of the operation, thus allowing timely verification and immediate correction of any technical problems with coronary artery bypass grafts.

[Early results of various surgical approaches in reconstruction of ascending aortic aneurysms]. / Rannie rezul'taty razlichnykh khirurgicheskikh podkhodov pri rekonstruktsii anevrizm voskhodiashchei aorty.

The study was aimed at analysing the immediate results of various surgical approaches to prosthetic repair of ascending aortic aneurysms. We analysed the data of 113 patients operated on for an ascending aortic aneurysm from 2008 to 2017. All patients were divided into two comparable groups. Group One patients (n=43) underwent prosthetic repair of the ascending portion of the aorta with formation of a distal anastomosis proximal to the level of the brachiocephalic trunk, Group Two patients (n=70) were subjected to reconstruction of the ascending aorta with aortic arch plasty ('hemiarch'). In the early postoperative period in Group One and Group Two patients, the frequency of adverse cardiac events amounted to 3 (7.0%) and 1 (1.5%) cases (p=0.339), with prolonged mechanical ventilation required in 12 (18.6%) and 6 (8.6%) cases and resternotomy required in 8 (18.6%) and 4 (5.7%) cases, respectively. The postoperative 30-day mortality in the group of isolated prosthetic repair of the ascending aorta amounted to 11.6% (5 cases) and in the group of patients with the hemiarch reconstruction to 3.0% (2 cases). No neurological complications were observed. Hemiarch prosthetic repair of the aorta is an effective and safe surgical method of treatment. This approach does not increase the risks for cardiac, neurological, pulmonary, haemorrhagic complications in the immediate postoperative period as compared with prosthetic repair of only the ascending portion of the aorta.

Five-year results of using the 'frozen elephant trunk' technique for thoracic aortic dissection. / Piatiletnie rezul'taty primeneniia metodiki 'zamorozhennyi khobot slona' pri rassloenii grudnoi aorty.

Analysed herein is efficacy of hybrid intervention according to the 'frozen elephant trunk' procedure in the medium-term period of follow-up in patients operated on for aortic dissection. During the period from 2012 to 2018, a total of 44 'frozen elephant trunk' procedures were carried out for Stanford type A and B thoracic aortic dissections. All interventions were performed in conditions of moderate hypothermic circulatory arrest (25-28 °C) with unilateral cerebral perfusion through the brachiocephalic trunk. The mean diameter of the implanted stent grafts amounted to 27.7±2.8 mm (range 24-30 mm). The distal edge of the stent graft was located at the level below the Th9 in more than 65% of cases (range Th7-Th12). The stent grafts were fixed proximally at the levels Z0-Z3, predominantly in the Z3 zone (72.7%). Thirty-day mortality amounted to 6.8%, with in-hospital mortality of 15.9%. Five-year survival in acute and chronic type A aortic dissection (AD) amounted to 100 and 80%, respectively (p=0.175). In acute type B aortic dissection five-year survival amounted to 62.2%, being 25.0% for chronic AD (p=0.057). Freedom from reinterventions for acute and chronic type A aortic dissection amounted to 100 and 66.7%, respectively (p=0.286). Freedom from aortic reinterventions for acute and chronic type B aortic dissection amounted to 100% and 75%, respectively (p=0.123). Reconstructive operations performed according to the 'frozen elephant trunk' technique appear to be effective surgical treatment in patients with thoracic aortic dissection, yielding satisfactory clinical results during a medium-term follow-up period.

[Functionality of mammary-coronary bypass grafts according to the data of intraoperative flowmetry]. / Funktsional'nost' mammarokoronarnykh shuntov po dannym intraoperatsionnoi floumetrii.

Improvement of surgical treatment for ischaemic heart disease is one of the main trends in modern medicine. After the operation of coronary bypass grafting, further functioning of blood flow in the grafts largely depends upon its domination over the native blood flow in the target coronary arteries. Therefore, intraoperative diagnosis of functional competence of coronary bypass grafts by means of flowmetry is currently of special importance. The purpose of this study was flowmetric quantitative assessment of the curves of blood flow through the coronary bypass grafts, depending on the degree of stenosis of the target coronary arteries. A total of 135 patients were examined during our study. We evaluated the curves of blood flow through the bypass grafts from the left internal thoracic artery to the anterior descending artery. The bypass grafts were divided into three groups: the 1st group (n=47) with moderate stenosis of the coronary arteries (from 50 to 75%); the 2nd group (n=42) with a more pronounced lesion of the target vessel (from 75 to 99%), and the 3rd group (n = 46) with occluded coronary arteries (100%). It was revealed that the flow rate (Q, ml/min) in group one was lower (17±3.1) than in group two (33±5.3) and group three (45±3.4). Also, differences were revealed in the resistance index of the grafts: it turned out to be higher in group one (5.2±1.1) and group two (4.5±0.9) as compared with group three (1.8±0.5). However, there was no between-group difference in diastolic filling of the grafts, which amounted to 58±13, 61±10 and 64±9% for groups one, two and three, respectively. By the shape of the curve, we assessed the reverse systolic peak whose presence prevailed in the grafts of group one (15 of 47; 31.9%) and group two (11 of 42; 26.2%) as compared with that in the grafts of group three (5 of 46; 10.8%). The obtained findings confirm higher frequency of the presence of competitive blood flow in the grafts used on non-occluded coronary arteries.

[Treatment of iatrogenic femoral artery pseudoaneurysms]. / Lechenie iatrogennykh lozhnykh anevrizm bedrennykh arterii.

The article is a review generalizing foreign and Russian experience and devoted to problems of diagnosis and treatment of iatrogenic false aneurysms of the femoral arteries. Based on the present-day scientific data, advantages and disadvantages of each of the currently existing therapeutic approaches are elucidated. Special attention is paid to the division dedicated to a promising minimally invasive trend in angiology, i. e. puncture obliteration of false aneurysms with the use of thrombin.

[Surgical correction of incomplete vascular ring in an adult female patient]. / Khirurgicheskaia korrektsiia nepolnogo sosudistogo kol'tsa u vzrosloi patsientki.

Described herein is a clinical case report concerning successful elimination of symptoms of oesophageal compression and the tracheobronchial tree in an adult female patient presenting with an incomplete vascular ring and the right-sided aortic arch with mirror-image branching of vessels.

[Single-centre experience with implantation of the 'E-vita open plus' hybrid stent graft]. / Odnotsentrovyi opyt implantatsii gibridnogo stent-grafta 'E-vita open plus'.

Hybrid technologies appear to have been gaining ground in surgery of the thoracic aorta. The present study was aimed at assessing the immediate clinical outcomes of surgical treatment of diseases of the thoracic aorta by means of the 'E-vita open plus' hybrid stent graft. The 'E-vita open plus' hybrid stent graft was implanted to 18 patients. All operations were carried out in the conditions of moderate hypothermia. The brain was protected by unilateral cerebral perfusion through the brachiocephalic trunk. The duration of artificial circulation averagely amounted to 265.1 [214; 281] min., with the mean aortic cross-clamping time equalling 150.8 [121; 177] min., and circulatory arrest lasting 55 [47.5; 62.5] min. In one (5.5%) case resternotomy was performed for haemorrhage. Five (27.8%) patients required haemodialysis to perform for postoperative renal insufficiency. A further five (27.8%) patients were found to have transient impairment of cerebral circulation. One (5.5%) patient was diagnosed as having haemorrhage into the area of the 'old ischaemic focus', one (5.5%) patient developed transient spinal ischaemia spontaneously disappearing within the first 24 hours. There were no cases of cardiac complications. A conclusion was drawn that hybrid operations according to the 'frozen elephant trunk' technique yield satisfactory immediate clinical results of treatment in patients with thoracic aortic aneurysms and dissection.

[Significance of the level of implantation of the 'E-vita open plus' hybrid stent graft into the descending aorta in the development of spinal ischaemic complications]. / Znachenie urovnia implantatsii gibridnogo stent-grafta 'E-vita open plus' v niskhodiashchuiu aortu v razvitii spinal'nykh ishemicheskikh oslozhnenii.

Spinal ischaemia in patients after reconstruction of the thoracic aorta is referred to the category of the most severe postoperative complications, especially in hybrid interventions. The present study was aimed at assessing the risks for the development of spinal ischaemia in patients after implantation of the 'E-vita open plus' stent graft into the descending portion of the thoracic aorta during hybrid reconstruction. The 'E-vita open plus' hybrid stent graft (Jotec, Germany) was implanted to 18 patients presenting with various pathology of the thoracic aorta (dissection, aneurysms). All operations were carried out in the conditions of moderate hypothermia, circulatory arrest and antegrade perfusion of the brain through the brachiocephalic trunk. It was determined that the distal end of the stent graft was located at the level of Th7-Th12. In 12 (66.7%) cases the 'lower' edge of the stent graft was located at the level of thoracic vertebrae Th8-Th9. Before the operation the number of open pairs of intercostal arteries amounted to 10 [9, 11]. After the operation, the number of the open pairs of the segmental arteries amounted to 3 [1; 4], they were all in the lower thoracic portion; the above-located intercostal arteries were shut by the stent graft. In 17 (94.5%) cases in the early postoperative period there were no signs of spinal ischaemia. Only one (5.5%) patient was clinically diagnosed to have developed transient spinal ischaemia noted to disappear spontaneously within the first 24 hours. A conclusion was made that using the 'E-vita open plus' stent graft in the course of hybrid reconstruction of the thoracic aorta was accompanied by the minimal risk for spinal ischaemic complications. The level of the location of the distal edge of the stent graft is not the determining factor in the risks of spinal complications in of such similar operations.

[Puncture treatment of pseudoaneurysms of femoral arteries with the use of human thrombin]. / Punktsionnoe lechenie lozhnykh anevrizm bedrennykh arterii s ispol'zovaniem chelovecheskogo trombina.

The authors analysed both immediate and remote results of puncture treatment with the use of human thrombin under ultrasound control in patients with iatrogenic false aneurysms of femoral arteries. The study included a total of 32 patients presenting with post-puncture pseudoaneurysms of femoral arteries after previous endovascular manipulations. The clinical diagnosis was verified by means of ultrasound duplex scanning. Puncture treatment was carried out using lyophilisate of human thrombin at a concentration of 500 IU according to the patented technique. The obtained outcomes were assessed at various terms (up to 12 months). The predominant ultrasound characteristics of a false aneurysm were as follows: an arterial defect sized 2.1-3 mm with prevailing localization in the superficial femoral artery (singe-chamber pseudoaneurysm with the volume of its cavity amounting to 31-60 cm3). The average dose of thrombin sufficient for obliteration of the cavity amounted to 320.8±104.6 IU. The puncture treatment proved to be effective in 30 (93.7%) patients. In the remaining 2 (6.3%) cases the outcomes of puncture treatment turned out unsatisfactory, thus requiring an operative intervention. No relapsed were observed in the remote period. A conclusion was drawn that puncture treatment is a highly effective method in relation to false aneurysms of femoral arteries and is neither accompanied by relapses nor followed by allergic, thrombotic, infectious complication at various terms of follow up. Efficacy of treatment with human thrombin does not depend on taking antithrombotic agents by the patients.

[Possibilities of "E-vita open plus" hybrid stent graft in surgery of thoracic aorta]. / Vozmozhnosti gibridnogo stent-grafta «E-vita open plus¼ v khirurgii grudnoi aorty.

BACKGROUND: The variety of pathology of the thoracic aorta supposes different approaches of surgical management, including the use of hybrid technologies. OBJECTIVE: To broaden a possible spectrum of indications for implantation of the "E-vita open plus" hybrid stent graft. RESULTS: Surgical treatment of thoracic aorta with the help of the "E-vita open plus" hybrid stent graft according to the "frozen elephant trunk" technique demonstrated satisfactory results in patients with various pathology: type A and B acute and chronic dissection according to the Stanford classification, as well as rare diseases (post-traumatic false aneurysm, complicated atherosclerosis of the thoracic aorta). CONCLUSION: The technology of "frosted elephant trunk" with implantation of the "E-vita open plus" hybrid stent graft in not limited by cases of acute aortic dissection, aortic aneurysmatic transformation and has wider indications for application. The use of this technology in cases of rare pathology of the thoracic aorta ("shaggy aorta" syndrome, posttraumatic false aneurysm) makes it possible to obtain satisfactory clinical results.

[Reconstructive surgery of aortic arch interruption in adults].

AIM: To evaluate surgical results in adults with aortic arch interruption. MATERIAL AND METHODS: Seven patients with aortic arch interruption were operated. Two of them (28.6%) underwent aortic arch repair using allograft, 4 (57.21%) - distal arch and proximal descending aortic replacement, 1 (14.3%) - supra-coronary ascending aortic, aortic arch and proximal descending aortic replacement. All operations were performed under moderate hypothermia (25 °Ð¡), circulatory arrest with unilateral cerabral perfusion 8-10 ml/kg/min via innominate artery and pressure 69.6±14.7 mm Hg in arterial. RESULTS: Cardiopulmonary bypass (CPB) time was 242±36.1 min, aortic cross-clamping - 110.7±40.4 min, circulatory arrest - 58.6±17.9 min. There were no cases of renal insufficiency, vascular lesion of brain and spinal cord, cardiac events. Resternotomy for bleeding was performed in 1 (14.3%) case. Sufficient descending aortic lumen was achieved in 100% according to CT postoperatively. Peak descending aortic pressure gradient after repair with allograft was 29±1.4 mm Hg, after aortic replaement - 10±4.2 mm Hg. Postoperative and in-hospital 30-day mortality was absent. CONCLUSION: Reconstructive surgery for aortic arch interruption in adults is effective approach with good clinical and hemodynamic results.

[Antegrade unilateral perfusion of the brain through the brachiocephalic trunk in operations on the aortic arch].

Presented herein is a technique of unilateral antegrade perfusion of the brain in operations on the aortic arch. The method makes it possible to perform both systemic artificial circulation and adequate physiological perfusion of the brain, promoting minimization of the number of neurological complications.

[Modern approaches to surgical treatment of post-injection vascular complications in intravenous drug addicts].

An ever-growing number of injection drug abusers causes great concern over specific post-injection complications involving major vessels, not uncommonly infected ones. The review is dedicated to the problem of vascular complications in drug abusers, clinical peculiarities of the nosology concerned, as well as a present-day view on diagnosis and policy of surgical treatment of infected false aneurysms in this cohort of patients. Surgical decision-making is based on a series of factors: baseline general condition of the patient, possibility of surgical care depending on the specific situation (scope and level of the infected area, phase of the course of the wound process, degree of ischaemia of the limb, choice of a plastic material), and probability of further injections of narcotic drugs. In treatment of such patients a promising trend includes endovascular and minimally invasive technologies, however assessing the remote results thereof requires accumulation of larger experience.

[Оperative treatment of an aortocaval fistula]. / Operativnoe lechenie aortokaval'noi fistuly.

Described herein is successful experience in surgical treatment of a patient presenting with a rare pathology, i. e. an aortocaval fistula which was the cause of non-cardiogenic heart failure. The leading role in the diagnostic search is assigned to contrast-enhanced multispiral computed tomography of the abdominal aorta.

[Intraoperative hypoxic preconditioning as a method of neuroprotection in operations on internal carotid arteries].

The present work was aimed at assessing safety and efficacy of hypoxic preconditioning of the brain as a method of protecting the central nervous system during operations on the internal carotid artery in patients presenting with atherosclerotic lesions of the carotid arteries. The study included a total of 72 patients who underwent carotid endarterectomy for haemodynamically significant atherosclerosis of carotid arteries. Based on the obtained findings, a conclusion was made on a possibility of using intraoperative hypoxic preconditioning for prevention of ischaemic complications from the development in the perioperative period.