[Effectiveness of biological prosthesis for femoro-femoral bypass in high risk patients]. / Éffektivnost' biologicheskogo proteza pri bedrenno-bedrennom shuntirovanii u lits s vysokim operatsionnym riskom.

AIM: To compare synthetic and biological prostheses for femoral bypass surgery. MATERIAL AND METHODS: There were 40 patients with critical ischemia of lower extremities due to atherosclerotic lesion of aorto-iliac segment and severe comorbidities. They were divided into 2 groups by 20 patients. C-shaped femoro-femoral bypass with synthetic polytetrafluoroethylene and lavsan prostheses was performed in the first group and S-shaped bypass procedure with biological prosthesis from the internal thoracic arteries of the bull - in the second group. RESULTS: Biological prosthesis is associated with reduced early postoperative morbidity by 10%, late graft thrombosis incidence by 20% and increased physical and psychological health by 7.1%. CONCLUSION: S-shaped femoro-femoral bypass with a biological prosthesis from the internal thoracic arteries of the bull is pathogenetically substantiated and effective.

[Results of administering oral anticoagulants for treatment of patients with venous thromboembolic complications]. / Rezul'taty primeneniia peroral'nykh antikoaguliantov pri lechenii bol'nykh s venoznymi tromboémbolicheskimi oslozhneniiami.

The objective of the study was to compare safety and efficacy of rivaroxaban and dabigatran with warfarin in treatment of patients with acute venous thromboembolic complications (VTEC). The authors analysed the results of examining and treating a total of 95 patients presenting with VTEC and randomly divided into three groups. In all groups the initial anticoagulant therapy consisted in unfractionated heparin administered for 5 days, after which the patients followed by switching were switched to a 6-month course of treatment with oral anticoagulants. Patients from Group One received warfarin, Group Two patients were treated with dabigatran etexilate, and Group Three patients were treated with rivaroxaban. Relapses of the disease were diagnosed in 2 (5.7%) patients from Group One. Haemorrhagic complications were noted in 8 (22.9%) Group One patients, in 3 (10%) Group Two patients and in 2 (6.7%) Group Three patients. After the end of treatment, complete recanalization of the thrombosed veins was revealed 13 (37.1%) patients from Group One, in 15 (50%) patients from Group Two and in 14 (46.7%) patients from Group Three. One year after the end of treatment, freedom from chronic venous insufficiency was observed in 8 (23.3%) patients of Group One, in 12 (40%) patients of Group Two and in 11 (36.6%) patients of Group Three. The composite quality of life indices after the treatment course were (appeared to be) higher in Group Two and Three patients compared with those of Group One. Hence, a conclusion was drawn that dabigatran and rivaroxaban turned out to be superior by efficacy and safety to warfarin in treatment of this patient cohort. No statistically significant differences were observed while comparing dabigatran and rivaroxaban.

[Results of using various methods of autovenous femoropopliteal bypass grafting below the knee-joint fissure]. / Rezul'taty primeneniya razlichnykh sposobov autovenoznogo bedrenno-podkolennogo shuntirovaniya nizhe shcheli kolennogo sustava.

The objective of the study was to improve therapeutic outcomes in patients presenting with lower limb critical ischaemia by means of optimizing the technique of femoropopliteal bypass grafting. The authors analysed the results of comprehensive examination and treatment of a total of 90 patients presenting with critical lower limb ischaemia on the background of atherosclerotic lesions of arteries of the femoropopliteal and crural segments. Depending on the technology of performing femoropopliteal bypass grafting, the patients were subdivided into three groups each consisting of 30 subjects. The groups were comparable by gender, age, concomitant diseases, degree of damage to arteries of the femoro-popliteal-crural segment, and the state of the distal vascular channel. Group One patients underwent conventional autovenous bypass grafting with a reversed great saphenous vein. Group Two patients endured surgery according to the "in situ" technique. Group Three patients were subjected to an original technology of bypass grafting using a free autovenous graft with destroyed valves without reversion of the vein. It was demonstrated that the use of a free autovenous transplant with destroyed valves increased the volumetric blood flow through the shunt in the remote postoperative period 2.4-fold as compared with the reversed vein and 1.7-fold as compared with the "in situ" autovein. The proposed technique of femoropopliteal bypass grafting made it possible in the immediate postoperative period to decrease the rate of early postoperative complications by 23.4% as compared with the option of using the reversed vein and by 13.3% as compared with the "in situ" technique, as well as to lower the incidence rate of late shunt thromboses by 40 and 13.3%, respectively, and the number of limb amputations by 30 and 6.7%, respectively. The use of a free autovenous graft with destroyed valves is pathogenetically justified and makes it possible to optimize the results of treatment of patients.

[Free autovenous graft with destructed valves in treatment of severe ischemia of lower extremities]. / Lechenie kriticheskoi ishemii nizhnikh konechnostei s ispol'zovaniem svobodnogo autovenoznogo transplantata s razrushennymi klapanami.

AIM: to improve treatment of patients with severe atherosclerotic lesion of lower extremities arteries followed by critical ischemia by optimization of femoropopliteal bypass surgery. MATERIAL AND METHODS: Treament and survey of 60 patients with severe atherosclerotic lesion of femoropopliteotibial segment and critical lower limb ischemia were analyzed. Patients were divided into 2 groups depending on technique of femoropopliteal bypass. Conventional in situ autovenous technique was used in group 1. In the second group we used original method of free autovenous graft with destructed valves. RESULTS: Technique of free autovenous graft with destructed valves decreases incidence of early postoperative complications by 13.3%, remote thrombosis of graft by 13.3%. Also it increases physical and mental components of health by 7.9% and 3.1% respectively. CONCLUSION: Use of free autovenous graft with destructed valves is reasonable and improves results of treatment.

EFFICACY OF FREE AUTOVENOUS TRANSPLANT IN FEMORAL-POPLITEAL BYPASS BELOW THE JOINT SPACE OF THE KNEE.

The article presents an analysis of complex examination and treatment of 60 patients with critical ischemia of the lower extremities due to atherosclerotic lesions of femoral-poplitealtibia segment. Typical traditional autovenous bypass of reverse big saphena was performed for the first (control) group of patients. The operation, which used an original technology by free autovenous transplant with collapsed valves without vein reverse, was completed for the second (experimental) group of patients. An application of original treatment technology allowed an increase of blood flow volume in the extremity in 1,5 times, an arterial blood flow - in 1,6 times, rate of microcirculation - in 1,3 times. An early postoperative complications were decreased on 23,4%, the late shunt thrombosis - on 40%. Long-term shunt passability was improved in 2,6 times and physical component of health - on 10,6%, psychological - on 4,3%. The shunt functioned in 36,7% of the first group and in 83,3% patients of the second group after two years since operation. The extremity was saved in 60% of the first group and 90% patients of the second group.

[CHOICE OF PROSTHESIS IN AXILLOFEMORAL BYPASS IN PATIENTS WITH HIGH RISK AND MULTILEVEL LESIONS OF LOWER LIMB ARTERIES].

An analysis of results of experimental research was made in 60 patients with critical ischemia of lower extremities due to bilaterally atherosclerotic lesions of aorto-iliac segment, which had a high operationally anaesthetic risk. Synthetic polytetrafluoethylene prosthesis or biological shunt from internal pectoral bull arteries were used as a shunt. Revasculization was performed through the system of arteria profunda femoris considering multilevel lesions of lower limb arteries. An application of biological prosthesis allowed decreasing the rate of early postoperative complications on 13,3% , late thromboses--on 30%, extending the medium term of shunt functioning in 1.8%, improving physical component of health on 12.8% and mental--on 9.1% during the immediate postoperative period. The experiments on rabbits were carried out. It was shown, that biological prosthesis had the greatest biological compatibility.

[Use of a biological graft for subclavian-femoral bypassing in patients at operational-anaesthesiological risk].

UNLABELLED: Analysed herein are the results of an experimental study performed on 30 rabbits and a clinical study of treating a total of 60 patients presenting with critical ischaemia of lower limbs on the background of bilateral atherosclerotic lesions of the aortoiliac segment and running high operational-anaesthesiological risk. The animals were subdivided into three groups: an intact group consisting of 6 animals and two study groups comprising 12 rabbits each. In the first study group onto the wall of the abdominal aorta we implanted a synthetic polytetrafluoroethylene prosthesis, the second study group animals received biological graft "Kemangioprotez" from bovine internal thoracic arteries. The biological prosthesis on day three after implantation onto the arterial wall induced 3.2 times and on day seven 1.2 times more pronounced inflammatory reaction than the polytetrafluoroethylene prosthesis. 30 days after implantation of the synthetic graft the degree of repair connective-tissue processes in the arterial wall was 1.8-fold and 70 days after was 3.3-fold more pronounced than after implantation of the biological prosthesis at the same terms. In the connective-tissue capsule around the synthetic prosthesis predominated cellular elements while around the biological prosthesis - fibrous structures predominated. The patients were subdivided into 2 groups consisting of 30 patients each. In Group One patients the shunt used was a synthetic polytetrafluoroethylene prosthesis, in Group Two being a biological graft from bovine internal thoracic arteries. All patients suffered from severe concomitant diseases in the decompensation stage and a multi-level lesion of lower-limb arteries. Revascularization of the ischaemized extremity was carried out through the system of the deep femoral artery system. The use of a biological prosthesis made it possible in the immediate postoperative period to decrease the frequency of early postoperative complications by 13.3%, that of late graft thromboses by 30%, to prolong the average term of grafts functioning 1.8-fold, to increase the physical component of health by 12.8% and the mental one by 9.1%. CONCLUSION: For femorosubclavian shunting in high-risk patients it is appropriate to use a biological graft while establishing a distal anastomosis with the deep femoral artery.

[Optimization of anticoagulation therapy for venous thromboembolism]. / Optimizatsiia antikoaguliantnoi terapii venoznogo tromboémbolizma.

OBJECTIVE: To optimize anticoagulation therapy for venous thromboembolism by means of dabigatran etexilate. MATERIAL AND METHODS: From 2006 to 2012, within the framework of the international trials RE-COVER and RE-COVER II aimed at evaluating efficacy and safety of dabigatran etexilate compared to warfarin, a total of 95 patients meeting the inclusion and exclusion criteria were enrolled in our study. As part of the RE-COVER trial, we carried out analysis of comprehensive examination and treatment of 55 patients with venous thromboembolism (VTE), who were randomly divided into two groups. Group I (Control Group) consisted of 30 patients receiving initial therapy with heparin for seven days followed by taking warfarin for six months. Group II (Study Group) comprised 25 patients taking dabigatran etexilate instead of warfarin. RESULTS: There were no cases of recurrent VTE in the Control Group, and one (4%) patient of the Study Group was found to have a relapse of the disease owing to resistance to anticoagulation therapy and congenital thrombophilia. Undesirable events of anticoagulation therapy developed in 20% of the Control Group patients an in 16% of the Study Group patients. In two Control Group patients and one Study Group patient anticoagulation therapy was discontinued due to the development of complications. After 2 years, 36.7% of the Control Group patients and 40% of the Study Group patients had no manifestations of chronic venous insufficiency (CVI). The degree of CVI was similar in the both groups. CONCLUSION: Dabigatran proved non-inferior to warfarin regarding efficacy, possessing, however, a series of advantages: it has a predictable anticoagulant effect, requires neither monitoring of the haemostasis system, nor dose adjustment, and is administered at standard dosages.

[Efficiency of bioprosthesis in case of axillary-femoral bypass in patients with high operative risk].

It was analyzed the treatment results of 60 male patients with critical limb ischemia in case of atherosclerotic lesions of the aorta-iliac segment and severe somatic diseases. All patients were divided into 2 groups. Every group consisted 30 patients. The first group included axillary-femoral bypass by using of synthetic polytetrafluoroethylene prosthesis. The second group - by using of bioprosthesis of bull's internal thoracic arteries. Using of bioprosthesis allows to reduce early postoperative complications in intermediate postoperative period on 13.3%, late bypass thrombosis on 30%. Also there was elongation of average time of bypasses functioning in 1.8 times. Physical health was increased on 12.8%, mental - on 9.1%.

[Advantages and disadvantages of warfarin and pradaxa therapy for venous thromboembolism].

An analysis of complex examination of 110 patients with venous thromboembolism was made. The patients were separated into 2 groups. The first group included 60 patients, who had the start heparin therapy during 7 days with the following 6-month warfarin therapy. Warfarin was substituted by pradaxa (dabigatran) for 50 patients of the second group. The efficacy of pradaxa could be compared with warfarin. However, pradaxa had a number of advantages such as the predictable anticoagulant effect, standard dosages. This medicine is more predictable and doesn't require a control of homeostasis and an adjustment of drug dosage.

[State of crural perforating veins after sclerosurgical interventions for lower limb varicose disease].

Analysed herein are the findings obtained by comprehensive examination of 106 patients presenting with grade C3 chronic venous insufficiency according to the CEAP classification. Localization, intensity and extent of refluxes of blood in the venous system of the affected extremity were determined by means of ultrasonographic angioscanning. Based on the obtained results, the patients were subdivided into two groups. Group One was composed of 87 (82.1%) patients found to have their perforant venous insufficiency caused by superficial hypervolemia due to sharply pronounced varicosity of superficial veins. Group Two comprised 19 (17.9%) patients who had developed perforant insufficiency secondary to superficial and deep blood refluxes. In 82 (77.3%) Group One patients, the scope of the operations was limited to elimination of the superficial blood reflux, with only five (4.7%) patients at the second stage of management had their perforant blood reflux removed. Group Two patients were subjected to single-stage removal of both superficial and perforant blood refluxes. Excellent therapeutic outcomes were observed in 49.1% of cases, with good and satisfactory results obtained in 41.5% and 9.4% of patients, respectively.

[Choice of the method of minimally invasive treatment of high venovenous blood reflux in patients with varicose disease of the lower extremity veins].

An analysis of complex examination and the following treatment of 337 patients with varicose disease was made. According to the results of the examination three groups of patients were established: the first group--of low intensive, the second group--of mean intensive, the third group--of highly intensive blood reflux. The patients of the first group were treated by the method of injection-sclerosing therapy. In the second group the sclero-surgical technology was used: after crossectomy into the lumen of the varicosity altered part of the great subcutaneous vein the sclerosing substance was administered through a catheter. In the third group ablation of the great subcutaneous vein of the femur was performed and obturation of the varicosity altered veins of the crus with the autovein ablated from the femur. In the first group recurrent diseases were noted in 9.1%, in the second group--in 9.4%, in the third--in 3% of the patients.

[Sclerotherapy of sapheno-femoral reflux of blood in patients with initial stages of varicose disease of the lower extremity veins].

The results of ultrasonic investigation and the following phlebosclerosing treatment of an incompetent saphenofemoral anastomosis were analyzed in two groups of patients with initial stages of varicose disease of the lower extremity veins. The first group included 48 patients treated by injection-sclerosing therapy by the technology of "empty vein". The second group consisted of 82 patients treated by catheter sclerotherapy of the sapheno-femoral anastomosis. In the first group the treatment was effective in 73.1%, in the second group - in 91.5%. The terminal hemodynamic criteria of performing the injectional and catheter sclerotherapy were determined in elimination of high sapheno-femoral reflux of blood.

[Role of blood refluxes in the genesis of venous trophic disorders in patients with chronic venous insufficiency].

The authors analyzed the results of a comprehensive examination of 120 patients with class C6 chronic venous insufficiency according to the CEAP classification, and open trophic ulcers. The patients were subdivided into 2 groups. Group One comprised a total of 75 patients with varicosity, and Group Two consisted of 45 patients with post-thrombotic disease. The localization, intensity and length of the refluxes of blood in the venous system of the affected extremity were determined by means of ultrasonographic angioscanning. Examining the patients with varicosity revealed that in 81.4% the main haemodynamic factor leading to development of the ulcer was a high-intensity, total-subtotal blood reflux along the superficial veins, and in 9.3% - high-intensity superficial and deep refluxes of blood. We failed to determine the blood reflux priority in 9.3% of patients. The trophic ulcers had developed under the effect of low-intensity refluxes of blood in the superficial, deep and perforating veins in elderly patients on the background of heart failure. The most damaging influence on the microcirculatory bed in patients with post-thrombotic disease with recanalization of deep veins is exerted by a high-intensity total reflux of blood in the popliteal and talocrural segments of the venous system of the lower extremities, which was revealed in 68.9% of patients. The developing pathological flow of blood from the muscular-venous pump of the cms into the deep veins of the foot induces perforating insufficiency on the foot and crus, thus creating two zones of venous hypertension above and beneath the ankle. The major factor of trophic ulcers development in patients with segmental obliteration (17.8%) and insufficient recanalization of deep veins (13.3%) was venous hypertension in the distal portions of the affected extremity. Blood refluxes in deep veins of the ankle were of a low-intensity pattern, and played an auxiliary role in development of trophic disorders.

[Treatment of critical lower limb ischemia at elderly and old patients with severe concomitant diseases].

Effect of 96% ethanol para-neural injection on sympathetic trunk has been studied experimentally on 18 rabbits. It is demonstrated that ethanol injection leads to dystrophic alteration of sympathetic ganglia and acute aseptic inflammation of para-neural tissues. Clinical study has been carried out on 40 elderly and old patients with critical lower limb ischemia and diffuse arterial occlusive disease. All the patients were divided into 2 equal groups. At the patients of 1st group the revascularizing osteo-trepanation of femur and crus was performed, at 2nd group this operation was completed with ultrasonic-assisted lumbar chemical desympathetization on affected side. At 20% of 1st group patients the symptoms of critical ischemia have not be eliminated; there were no negative dynamics of ischemia at the patients of 2nd group.

[Lumbar chemical sympathectomy in complex treatment of critical impairments of microcirculation in patients with decompensated forms of chronic venous insufficiency].

The authors describe a method of chemical lumbar sympathectomy under USI control in 40 patients. No complications were noted. Positive effect was observed for 2 months.

[Experimental and clinical grounds of revascularizing osteomyoplasty for treatment of critical ischemia of the lower extremities].

In an experimental work it was found that under conditions of muscle ischemia the revascularizing osteomyoplasty was better than revascularizing osteotrepanation: it resulted in 1.4 times greater diameter of muscle fibers and 1.3 times larger size of the capillary network. An analysis of treatment of 30 patients was made who had critical ischemia of the extremities against the background of a diffuse lesion of the arteries below the inguinal ligament. In the first group consisting of 15 patients standard revascularizing osteotrepanation of the femur and shin was performed, in the second group (15 patients) revascularizing osteomyoplasty on the shin was added to the revascularizing osteotrepanation on the femur. In the second group the percentage of "mild improvement" of the clinical status of the patients was 10 times greater, and the number of patients with "minimal improvement" was 3.7 times less.

[Effects of blood refluxes on formation of trophic ulcers in patients with postthrombotic disease].

The results of complex examination of 45 patients with chronic venous insufficiency having class C6 open trophic ulcers by CEAP classification due to postthrombotic disease were analyzed. The localization, intensity and duration of blood refluxes in the venous system of the injured extremity were determined using ultrasonic angioscanning. Highly intensive total reflux of blood in the popliteal and talocrural segments of the lower extremity venous system found in 68.9% of patients has most injuring effects on the microcirculatory bed of patients having postthrombotic disease with recanalization of the profound veins. The developing pathological cross-flow of blood from the musculo-venous pump of the shank into the foot profound veins gives rise to perforator vein incompetence on the foot and shank forming two zones of venous hypertension under and over the ankle-bone. The main factor of the developing trophic ulcers in patients with segmental obliteration (17.8%) and insufficient recanalization of the profound veins (13.3%) was venous hypertension in the distal parts of the injured extremity. Blood refluxes in the shank profound veins were weakly intensive and played a subsidiary role in the development of trophic disorders.

[Hemodynamic characteristics and surgical treatment of varicose disease with primary involvement of deep vein valves].

Results of clinical examinations and ultrasonic duplex scanning of the venous system of the lower extremities performed in 31 patients with the varicose disease were analyzed. The disease developed due to the primary valve insufficiency of the profound veins. This form is characterized by total-subtotal refluxes of blood along the subcutaneous veins, multiple lesions of the perforant veins, the presence of the hemodynamically valuable blood refluxes in the profound and muscle veins. The hemodynamic parameters of blood flow and the technology of surgical treatment of the deep, superficial, perforant and muscle blood refluxes are shown allowing to restore the quality of life in 76.7% of the patients and considerately improve it in 23.3%.

[Sclerotherapy of high venovenous blood reflux in patients with early varicose disease of the lower extremities].

Results of diagnosis and treatment of 270 patients with varicose disease were analyzed. Based on duplex scanning two groups of patients were divided: group 1 consisted of 164 patients with low-intensity reflux, group 2 consisted of 106 patients with high-intensity reflux. Patients of group 1 were treated with ultrasound-assisted puncture sclerotherapy. In group 2 sclerosurgical procedures were used: sclerosant was injected into great saphenous vein trough catheter after crossectomy. For obliteration of varicose subcutaneous veins and perforants of shank the Irish technique was used. In group 1 recurrence of the disease was revealed in 9.1% patients, in group 2 -- in 9.4% patients.