[Endovascular and hybrid treatment of thoracic and thoracoabdominal aortic aneurysms and dissections]. / Éndovaskuliarnoe i gibridnoe lechenie anevrizm i rassloenii grudnoi i torakoabdominal'noi aorty.

The article deals with immediate and medium-term results of hybrid and endovascular treatment of 74 patients with various pathologies of the thoracic and thoracoabdominal aorta (31 with aneurysms, 43 with thoracic and thoracoabdominal aortic dissections). Elective and emergency interventions were performed in 49 and 25 patients, respectively. Endoprosthetic repair of the arch, descending thoracic and thoracoabdominal aorta was performed in 25 patients, hybrid operations in 47 subjects (open switch of brachiocephalic, visceral and renal arteries followed by aortic endoprosthetic repair - 37, endovascular methods of making a landing zone - 12). The duration of the follow-up period after discharge from hospital amounted to 24.9±16.3 months. The technical success level was 98.6%. The overall hospital mortality rate was 11% (n=8), elective - 4% (n=2), emergency - 24% (n=6). Eight patients underwent repeat interventions on the thoracic and thoracoabdominal aorta. The 5-year cumulative survival rate was 82.3%, with freedom from repeat interventions amounting to 51.3%. Hybrid operations on the arch and descending thoracic aorta are considered to be a relatively safe and effective method of treatment. Follow-up and timely treatment of remote complications after hybrid or endovascular operations are obligatory for improving the results.

[Open prosthetic repair of descending aortic aneurysm after its primary endoprosthetic repair]. / Otkrytaia operatsiia protezirovaniia anevrizmy niskhodiashchego otdela aorty posle ee pervichnogo éndoprotezirovaniia.

Presented in the article is a clinical case report regarding management of an 82-year-old female patient with late complications after staged treatment for an aneurysm of the descending and abdominal portions of the aorta, with the first stage consisting in endoprosthetic repair of the descending aortic portion and the second stage (after 4 months) in endoprosthetic repair of the abdominal aortic portion. Outpatient computed tomography performed 9 months after endoprosthetic repair of the abdominal aorta revealed an increase in aortic diameter over the distance between two stent grafts in the thoracic and abdominal aortic portions from 44 mm to 76 mm. In May 2019, a repeat operation was performed: resection of the aneurysm of the distal portion of the descending aorta on temporary subclavian-femoral and prosthesis-femoral shunts, with dissection of part of the thoracic stent graft, followed by formation of a proximal anastomosis between the endoprosthesis and a 30-mm linear Dacron prosthesis, and a distal anastomosis above the celiac trunk. The woman was discharged on POD 16. Follow-up computed tomography performed 8 months later demonstrated a type II endoleak from the inferior mesenteric artery and growth of the abdominal aortic aneurysm, thus requiring embolization of the ostium of the inferior mesenteric artery via the system of the superior mesenteric artery, with a good clinical effect and a decrease in the diameter of the aortic abdominal aneurysm.

[Surgical treatment of a patient with traumatic rupture of the aortic arch and late oesophageal perforation]. / Khirurgicheskoe lechenie bol'nogo s travmaticheskim razryvom dugi aorty i pozdnei perforatsiei pishchevoda.

Described herein is a clinical case report regarding a patient presenting with traumatic rupture of the aortic isthmus with the development of a pseudoaneurysm occupying virtually the entire posterior mediastinum and measuring 20?10 cm in size. He was immediately treated as an emergency to undergo prosthetic reconstruction of the portion of the aortic arch and descending thoracic aorta by means of temporary bypass grafting with a synthetic graft in order to protect the visceral organs. The postoperative period was complicated by oesophageal perforation with the formation of an oesophago-paraprosthetic fistula, infection of the vascular graft, accompanied by the development of pleural empyema and mediastinitis. A second operative procedure was performed, consisting of subclavian-iliac bypass grafting on the right with a polytetrafluoroethylene graft measuring 20 mm in diameter, exclusion of the intrathoracic portion of the oesophagus, creation of a gastro- and oesophagostoma, retrieval of the vascular graft followed by suturing of the aorta, pleurectomy, decortication of the lung, and removal of the empyemic sac on the left. There was no evidence of ischaemia of the spinal cord or visceral arteries. One month postoperatively, he underwent a traumatological stage and 4 months thereafter plasty of the oesophagus with an isoperistaltic gastric pedicle, extirpation of the thoracic portion of the oesophagus, to be later on followed by closure of the oesophagostoma. The patient experienced no difficulties either while walking or during other physical activities, with the ankle-brachial index amounting to 0.9. With time, he developed difficult-to-correct pulmonary hypertension. Unfortunately, the patient eventually died of acute cardiopulmonary insufficiency 9 years after right-sided extra-anatomical subclavian-iliac bypass grafting.

[Surgical treatment of a huge paraganglioma of the right common carotid artery bifurcation]. / Khirurgicheskoe lechenie krupnoi paragangliomy bifurkatsii pravoi obshchei sonnoi arterii.

Described herein is a clinical case report regarding successful surgical treatment of a female patient presenting with a large paraganglioma of the right common carotid artery. On admission, the woman had complained of a mass in her neck, having significantly enlarged within the previous 6 months, with the appearance of dysphagia and moderate pain syndrome. The findings of multislice computed angiography and ultrasonographic duplex angioscanning of the brachiocephalic arteries helped to verify the location, size, and topography of the tumour. Taking into account the diagnosed secondary foci in the lungs, it was decided to first perform embolization of the artery supplying the tumour, which was followed by biopsy of tissue of the neoplasm. After histological verification and ruling out malignancy, successful radical resection of the paraganglioma was performed.

[Hybrid treatment of a patient with dissecting thoracoabdominal aortic aneurysm and single kidney]. / Gibridnye tekhnologii v lechenii patsienta s rassloivsheisia torakoabdominal'noi anevrizmoi aorty i edinstvennoi pochkoi.

Presented herein is a clinical case report regarding a repeat intervention for a type II dissecting thoracoabdominal aortic aneurysm treated by means of a hybrid technique in a 76-year-old male patient with a single kidney, having 9 years previously endured resection of an aneurysm of the infrarenal aortic portion. The first stage consisted in prosthetic repair of the thoracoabdominal aortic aneurysm by an oblique anastomosis, with the second stage (7 days thereafter) being endoprosthetic repair of the descending thoracic aorta. The findings of check-up computed tomography at 16 months postoperatively demonstrated no negative dynamics.

[Bypass grafting in patients with infected vascular grafts]. / Obkhodnoe shuntirovanie pri infitsirovanii sosudistogo proteza.

Analysed herein are the results of treating a total of 17 patients presenting with pathology of the aorta and lower-limb arteries, who from 2010 to 2018 required redo interventions due to infection of a previously implanted synthetic vascular graft. At admission, 3 patients were diagnosed as having an open infected wound, 11 were found to have a fistula, 2 had a false aneurysm in the area of the distal anastomosis of the branch of the bifurcation aortofemoral prosthesis, and 1 had thrombosis of the branch of the prosthesis with evidence of infection. As redo surgery, 4 patients underwent subclavian-femoral bypass grafting, 2 were subjected to crossover iliac-femoral bypass grafting, 8 to unilateral iliac-femoral bypass grafting, 3 to loop endarterectomy. In the majority of cases (14 of the 17) we used bypass grafting with creation of the tunnel through the muscular lacuna. Lethal outcomes were registered in 35% (n=6) of cases in the early postoperative period. Death was caused by acute renal failure in 6% (n=1), by acute mesenteric thrombosis in 12% (n=2), by gastrointestinal haemorrhage in 6% (n=1), and by multiple organ failure in 12% (n=2). Long-term mortality amounted to 33% (n=3) within 12 months. The main causes of death were increasing renal failure in 10% (n=1) and cardiovascular insufficiency on the background of heart diseases in 10% (n=1), as well as respiratory insufficiency in 10% (n=1). Reinfection in the remote period was diagnosed in 1 patient. A conclusion was drawn that bypass grafting is traumatic, however, it may be the only way to save the limb or patient's life in a complicated clinical situation. Using the superficial femoral vein as a shunt demonstrated good long-term results as to patency and resistance to surgical infection. Using a flap of the greater omentum, retroperitoneal fat, as well as wrapping of the prosthesis with a muscular flap ensured good tolerance of the zone of bypass grafting to reinfection.

[Elimination of late endoleak after endovascular repair of a dissecting thoracoabdominal aortic aneurysm]. / Likvidatsiia pozdnego éndolika posle éndoprotezirovaniia rassloivsheisia torakoabdominal'noi anevrizmy aorty.

Described herein is a clinical case report regarding treatment of a 70-year-old male patient presenting with a late complication following endoprosthetic repair for a Stanford type B dissecting thoracic aortic aneurysm. The man was admitted to our hospital for persistent type IIb endoleak and an increased diameter of the aorta in its thoracic and thoracoabdominal portions. Two years previously, he had endured endoprosthetic repair of the thoracic aorta. The findings of computed tomography revealed negative dynamics manifesting as an increase in the diameter of the false channel of the arch and descending thoracic aorta with persistent type IIb endoleak. He was subjected to elimination of abdominal aortic dissection and type IIb endoleak with partial prosthetic repair of the descending thoracic portion of the aorta by means of prosthetic repair of the lower thoracic portion of the aorta between the stent graft and linear vascular Dacron prosthesis. The postoperative period was complicated by transient acute renal failure and paraparesis of the lower limbs. The patient was discharged on POD 14, with no endoleaks revealed on control computed tomography 3 months thereafter.

[Open surgical treatment of aneurysms and dissection of the thoracic and thoracoabdominal aorta]. / Otkrytoe khirurgicheskoe lechenie anevrizm i rassloeniia grudnoi i torakoabdominal'noi aorty.

Presented herein is experience in treating a total of 56 patients with pathology of the arch, descending and thoracoabdominal aorta from 1997 to 2017. Of these, 6 (11%) patients were diagnosed with a Crawford type I-II thoracoabdominal aortic aneurysm (TAAA), 20 (35%) patients with Crawford type III-IV TAAA, 18 (32%) were diagnosed as having an aortic arch aneurysm (AAA) and descending thoracic aortic aneurysm (DTAA), 12 (22%) had DeBakey type I and IIIb aortic dissection. To protect the visceral organs and spinal cord from ischaemia in 28 (50%) cases we used a temporal bypass from a synthetic vascular graft with zero porosity and measuring from 15 to 20 cm in diameter. RESULTS: Mortality within 30 days amounted to 14.3% (n=8), that after 30 days amounted to 10.7% (n=6): in elective operations - 12% (n=5) and 5.4% (n=3), in emergency operations - 21% (n=3) and 21.4% (n=3), respectively. The total in-hospital mortality amounted to 25% (n=14), equalling 19% (n=8) and 43% (n=6) for elective and emergency operations, respectively. Mortality in using temporal bypass in elective operation amounted to 9.5% (n=2) during 30 days and that without using this method to 14.3% (n=3), after 30 days being 9.5% (n=2) and 4.7% (n=1), respectively. Mortality for emergency cases with a temporal shunt during 30 days was 28.6% (n=2), without - 14.3% (n=1), after 30 days - 28.6% (n=2), without - 14.3% (n=1). In type I-II TAAA mortality within 30 days was 16.6% (n=1), after 30 days - 50% (n=2); type III-IV TAAA - 10% (n=2) and 15% (n=1); DTAA - 22.2% (n=4) and 33.3% (n=2); aortic dissection - 8.3% (n=1) and 16.6% (n=1). Acute renal failure (ARF) occurred in 6 (10.7%) patients and was more often observed in the group without temporal shunting. Events of spinal cord ischaemia with the development of spinal stroke occurred in 6 (10.7%) cases. Five-year survival amounted to 61%. CONCLUSION: Temporal bypass in surgery of the thoracic and thoracoabdominal aorta may be used for prevention of ischaemia of visceral organs, kidneys and spinal cord in operations accompanied by cross-clamping of the descending thoracic aorta.

[Surgical treatment of total thrombosis of an abdominal aortic endograft]. / Khirurgicheskoe lechenie total'nogo tromboza éndoproteza briushnoi aorty.

Described in the article is a clinical case report regarding successful surgical treatment of total thrombosis of a stent graft in a high-risk surgical patient, having previously undergone endovascular repair of an abdominal aortic aneurysm by means of a unilateral stent graft with suprarenal fixation of its crown and femorofemoral crossover bypass grafting. 5 months after the operation, the patient began complaining of rest pain in his right leg and trophic ulcers of the foot. The findings of MSCT angiography revealed total thrombosis of the stent graft, to be later on followed by operative intervention, i. e. resection of an infrarenal abdominal aortic aneurysm with the removal of the stent graft, aortofemoral bifurcation prosthetic repair and graft-renal prosthetic repair on the left. The postoperative period was complicated by a transitory ischaemic attack. On POD 29, the patient was discharged in a satisfactory condition. 8 months later, the findings of the control MSCT angiography revealed thrombosis of the graft of the left renal artery, with the left kidney secondarily shrunken. However, the clinical biochemistry data showed no evidence of renal failure, thus suggesting that renal function was compensated exclusively at the expense of the right kidney.

[Hybrid surgical treatment of a multilevel lesion of lower-limb arteries]. / Gibridnoe khirurgicheskoe lechenie mnogourovnevogo porazheniia arterii nizhnikh konechnostei.

The study was aimed at assessing immediate postoperative and remote results of hybrid surgical treatment of patients with a multilevel lesion of lower-limb arteries. Described herein is the authors' experience with simultaneous hybrid surgical management of 48 patients, including 43 subjects with a multilevel lesion of arteries of the lower extremities. There were 40 men and 8 women, with the average age amounting to 65.8±7.9 years. Of these, 30 patients suffered from stage II-b chronic arterial insufficiency (CAI), 11 had stage III CAI and 7 had stage IV CAI according to A.V. Pokrovsky classification. While planning the hybrid operation on the arteries of lower limbs we assessed the type of the lesion to the aortofemoral and femoropopliteal segments according to TASC II. All patients were subdivided into 3 groups, depending on the type of hybrid operations: Group I (n=17) - aortofemoral segment, Group II (n=5) - femoropopliteal segment, and Group III (n=26) reconstruction of both above-mentioned segments. The technical success amounted to 93.7% in revascularization of all types of lesions of the arteries of lower limbs with the use of hybrid vascular reconstructions. The mean duration of the operation was 231.8±90.7 min, including that of the open stage amounting to 126.4±72.8 min and that of the endovascular stage to 105.4±62.9 min. In the immediate postoperative period there were 2 complications requiring repeat reconstructive operation. The ankle-brachial index (ABI) after the intervention increased from 0.43±0.17 to 0.85±0.12. The duration of follow-up averaged 23.4±15.1 months (range 1.9-45.2 mos). Primary patency at 6 months was 94%, at 12 months 94%, at 24 months - 85% and at 36 months - 79% in all groups studied. Four patients during the follow-up period were subjected to amputation. The limb salvage rates were as follows: during 36 months in all patients - 91.6%, in those with stage II-b CAI - 93.3% and in those with critical lower-limb ischaemia - 88.8%. The overall survival rate was 95.8%. The use of a hybrid method in treatment of a multilevel lesion of lower-limb arteries with revascularization of the aortofemoral and femoropopliteal segments proved efficient both in the immediate and remote periods.

[Treatment of an aortic arch aneurysm ruptured into the lung]. / Lechenie razryva anevrizmy dugi aorty s proryvom v legkoe.

Described herein is a clinical case report concerning treatment of a 32-year-old female patient with rupture of an aneurysm of the arch and descending portion of the thoracic aorta, with the bleeding having penetrated the upper lobe of the left lung. The woman was admitted to the Department of Vascular Surgery of Municipal Multimodality Hospital No 2 of Saint Petersburg, presenting with a clinical pattern of aneurysmal rupture previously diagnosed by computed tomography performed at one of the local hospitals. Studying her case history revealed that, when a child, she had endured an operation for a defect of the interventricular septum and aortic coarctation with aortoplasty using a Dacron synthetic patch. On admission, she was treated as an emergency to immediately undergo temporal ascending-descending bypass grafting of the aorta and left common carotid artery without use of a heart-lung machine. After resection of the aneurysm of the arch and descending portion of the thoracic aorta and removal of the upper lobe of the left lung, a decision was made to leave the temporal shunt as permanent. In the early postoperative period the woman developed acute cerebral circulation impairment with minimal neurological deficit which was later on relieved. After 22 days, due to persisting atelectasis of the lower lobe of the left lung, the presence of an incompetent stump of the upper bronchus and air in the left pleural cavity, as well as high risk of infection of the vascular graft, we performed final bilateral pneumonectomy with omentopexy, i. e., suturing of the greater omentum to a portion of the thoracic graft. The woman was discharged on postoperative day 34 in a satisfactory condition. She then successfully gave birth to a child. She is currently presenting neither complaints nor evidence of respiratory insufficiency. The duration of follow up amounted to 8 years.

[Successful two-stage surgical treatment of a thoracoabdominal aortic aneurysm: a case report]. / Sluchai uspeshnogo dvukhétapnogo khirurgicheskogo lecheniia torakoabdominal'noi anevrizmy aorty.

Presented herein is a clinical case report regarding hybrid or two-stage surgical treatment of a Crawford type II thoracoabdominal aortic aneurysm in an 87-year-old woman. For the first stage operation we performed open resection of the abdominal aortic aneurysm with aortofemoral bifurcation prosthetic repair and debranching of visceral and renal arteries. Several months thereafter, the second stage operation was performed, consisting in transcatheter exclusion of the thoracoabdominal aortic aneurysm with the help of two stent grafts. The postoperative period turned out uneventful, with no complications. The check-up contrast-enhanced multislice computed tomography (MSCT) carried out 8 months later showed neither endoleaks nor migration of the stent grafts, with the bypass shunts' patency preserved.

[Hybrid treatment of patients with aneurysms and dissections of the aortic arch and descending portion of the thoracic aorta]. / Gibridnoe lechenie bol'nykh s anevrizmami i rassloeniiami dugi i niskhodiashchego otdela grudnoi aorty.

The authors share herein their experience with hybrid surgical treatment of 21 patients presenting with lesions of the aortic arch and descending thoracic aorta. Aortic pathology included dissection of the thoracoabdominal aorta (n=15), a sacciform aneurysm of the aortic arch (n=5), and a spindle-shaped aneurysm of the distal portions of the aortic arch (n=1). The first stage consisted of the following operations: transposition of the left subclavian artery into the left common carotid artery (n=9; 42.8%), partial debranching (n=11; 52.5%), and total debranching (n=1; 4.7%). The second stage consisted in implantation of a stent graft: to the thoracic aorta in 18 (85.8%) cases, and to the thoracic and abdominal portions of the aorta in 3 (14.2%) cases. The most significant complications of the immediate postoperative period included acute cerebral circulation impairment (n=1) and local dissection of the ascending aorta (n=1). Type I endoleaks were observed in 4 (19%) patients, type II endoleaks in 1 (4.7%), and type III endoleaks in 1 (4.7%). The mean duration of the follow up after discharge from hospital amounted to 11.6±7.9 months. In 4 patients after 6 months the findings of the control MSCT angiography showed no significant changes of the endoleaks. 1-year patency of the shunted branches of the aortic arch amounted to 95.2%. The cumulative survival rate amounted to 95.2%.

[Open surgical treatment of a giant renal cyst on the background of an arteriovenous fistula of the right renal artery]. / Otkrytoe khirurgicheskoe lechenie gigantskoi kisty pochki na fone arteriovenoznogo svishcha pravoi pochechnoi arterii.

Presented herein is a clinical case report concerning open surgical treatment of an arteriovenous fistula of the renal artery with a large venous aneurysm in the hilum of the right kidney and a giant cyst of the upper pole in a 28-year-old woman. The intraoperative findings revealed disunion of the arteriovenous fistula, followed by edge-to-edge suturing of the arterial defect. The venous aneurysm in the hilum of the right kidney was dissected and sutured by the edge-to-edge technique, with the additional varicose renal vein ligated. The postoperative period turned out to be uneventful with favourable convalescence and no complications. The check MSCT angiography performed 3 months later showed that the venous aneurysm was thrombosed, with no evidence of arterial blood ingress revealed. The excretory function of the kidney was preserved. Also discussed in the article are variants of diagnosis and treatment of an arteriovenous fistula of this localization and complications thereof.

[Operation for a giant pseudoaneurysm of the aortic arch without artificial circulation]. / Operatsiia pri gigantskoi lozhnoi anevrizme dugi aorty bez ispol'zovaniia iskusstvennogo krovoobrashcheniia.

Presented herein is a variant of surgical management of a patient with a giant false aneurysm of the aortic arch in the posterior mediastinum. Using the technique of temporary bypass or temporary "debranching" made it possible to carry out a reconstructive intervention without the use of an artificial circulation apparatus. This technique also decreases the necessity of using heparin, thus diminishing the risk of blood loss both during the operation and in the postoperative period. The described variant of the operation for a false aneurysm of the aortic arch extends and supplements the surgeon's capabilities of performing interventions on the aortic arch in the absence of a possibility of using an artificial circulation apparatus both in a scheduled and emergency situation.