[Does an attempt to save a limb always prolong the patient's life?] / Vsegda li popytka sokhranit' konechnost' prodlevaet zhizn' patsienta?

AIM: The purpose of the study was to examine overall survival and the incidence of major adverse cardiovascular events, as well as economic expenditures for treatment of patients with occlusion of the femoropopliteal-tibial segment and critical ischaemia in low competence of the outflow channel, with a poor prognosis for endovascular or open revascularization of lower-limb arteries. PATIENTS AND METHODS: We studied the results of treating a total of 68 patients with lower-limb critical ischaemia and low parameters of the outflow channel competence. Primary arterial reconstruction was performed in 48 cases. At various terms after revascularization due to thrombosis of the reconstruction zone and the development of gangrene, amputation of the lower limb was performed: at 3 to 11 (n=25) and at 12 to 24 (n=25) months. Primary amputation of the lower limb was performed in 20 patients. The endpoints of the study included overall survival, the incidence of major adverse cardiovascular events, and economic expenditures for the in-hospital treatment. The average duration of follow-up amounted to 2 years. RESULTS: The obtained findings demonstrated that in patients with lower-limb critical ischaemia and low parameters of the outflow channel competence, redo arterial reconstructions and amputation within 11 months, as well as a high level of surgical risk were associated with a low overall survival rate and the development of major adverse cardiovascular events in the remote period. Secondary surgical interventions on the major vessels significantly increased the cost of treatment.

[Surgical policy of managing patients with concomitant atherosclerotic lesions of the internal and common carotid arteries]. / Khirurgicheskaia taktika vedeniia bol'nykh pri sochetannom ateroskleroticheskom porazhenii vnutrennei i obshchei sonnykh arterii.

AIM: The purpose of this study was to investigate the natural course of stenosis of the common carotid artery (CCA) after carotid endarterectomy, as well as the long-term outcomes of various methods of reconstruction of the internal carotid artery (ICA) in patients with extended atherosclerotic lesions. PATIENTS AND METHODS: Presented herein are the remote retrospective and prospective results of carotid endarterectomy in a total of 78 patients with concomitant atherosclerotic lesions of carotid arteries. Depending on the degree of CCA stenosis, the patients were divided into 2 groups. Group One (n=25): stenosis of the internal carotid artery (ICA) of more than 70% and haemodynamically insignificant (30-35% stenosis) but extended (from 3.0 to 5.0 cm (Q1, Me, Q3); 3.5 cm, 4.0 cm, 5.0 cm) stenosis of the CCA. These patients underwent carotid endarterectomy (CEA) from the ostium of the ICA, during which an atherosclerotic plaque was not completely removed from the CCA because the stenosis was extended but haemodynamically insignificant. Group Two (n=53): stenosis of the ICA of more than 70% and haemodynamically significant, extended (from 7.0 to 10.0 cm (Q1, Me, Q3); 7.5 cm, 8.0 cm, 9.0 cm) stenosis of the CCA. The patients of this group were subjected to various methods of operative intervention on the ICA and CCA: carotid endarterectomy (ECA) combined with open endarterectomy from the CCA with plasty using the primary suture (n=23); carotid endarterectomy and alloreconstruction of the CCA (n=10); simultaneous eversion endarterectomy from the ICA and CCA (n=20). The remote period of follow up of patients ranged from 14 to 24 months ((Q1, Me, Q3; 19 months, 22 months, 24 months). The differences were statistically insignificant (Mann-Whitney U-test, p=0.881). RESULTS: In the remote postoperative period, 32% of Group One patients after previously performed carotid endarterectomy were found to have an increase in the degree of stenosis of the CCA up to a haemodynamically significant one (70% and more), thus suggesting progression of the atherosclerotic process. In Group Two patients, after plasty of the CCA with the primary suture, 21.7% of patients were diagnosed as having restenosis of the reconstruction zone up to 30%, with no neurological deficit. 20% of patients after carotid endarterectomy and alloreconstruction of the CCA were diagnosed as having restenosis of the reconstruction zone more than 70% and acute impairment of cerebral circulation with a lethal outcome. The patients after simultaneous eversion endarterectomy form the ICA and CCA in the intraoperative and postoperative periods had neither restenosis of the reconstruction zone nor neurological deficit. CONCLUSION: 32% of patients after previously performed carotid endarterectomy with the presence of extended, but haemodynamically insignificant stenosis of the CCA (30-35% stenosis) in the postoperative period were found to have progression of the atherosclerotic lesion in the form of an increased degree of stenosis up to haemodynamically significant (more than 70%), thus requiring repeat reconstructive operation. Therefore, in patients presenting with concomitant atherosclerotic lesions of the carotid arteries it is appropriate to carry out operative intervention simultaneously on the ICA and CCA, which would make it possible to considerably improve the remote postoperative results of reconstructive interventions on the carotid basin in this cohort of patients. A comparative study of the outcomes of various methods of reconstruction of carotid arteries in patients with concomitant atherosclerotic lesions of the ICA and CCA demonstrated that simultaneous eversion endarterectomy from the ICA and CCA resulted in good postoperative parameters: absence of restenosis and neurological deficit in the remote period of follow up.

[Antithrombotic therapy after bypass grafting below the inguinal ligament]. / Antitromboticheskaia terapiia posle shuntirovaniia nizhe pakhovoi sviazki.

The importance of antithrombotic therapy following reconstructive operations on arteries below the inguinal ligament is beyond question. The pharmaceutical market offers a wide variety of antiaggregant and anticoagulant agents, with many studies (including randomised and multicenter ones) performed worldwide on the problem of choosing optimal antithrombotic therapy in the postoperative period after arterial reconstructions. Nevertheless, the problem of selecting adequate antithrombotic therapy after shunting operations remains undetermined. Presented in the article is a review of foreign studies on the problem concerned. This is followed by discussing the results of many large international studies, including such trials as the BOA and CASPAR. Based on the findings obtained in these studies, Cochrane reviews, European and American guidelines, the authors express their opinion on the algorithms of choosing an appropriate variant of antithrombotic therapy during the postoperative period in patients after arterial reconstructions below the inguinal ligament.

[Remote results of carotid endarterectomy in patients with type 2 diabetes mellitus]. / Otdalennye rezul'taty karotidnoi éndarteréktomii u bol'nykh s sakharnym diabetom II tipa.

The authors comparatively analysed the remote results of carotid endarterectomy and risk factors for unfavourable outcomes in patients with and without type 2 diabetes mellitus (DM). The outcomes of carotid endarterectomy were studied in a total of 168 patients, with the follow-up terms up to 8 years. Depending on the presence or absence of DM, the patients were divided into two groups. Group One comprised 79 patients with an atherosclerotic lesion of the internal carotid artery and accompanying DM, with Group Two consisting of 89 non-diabetic patients. There were no lethal outcomes in the early postoperative period. The composite measure 'lethality + stroke' in Group One amounted to 2.5% and in Group Two to 2.2%. In the remote period the survival rate was as follows: 65 (82.3%) people for Group One and 83 (93.3%) for Group Two, with the 5-year cumulative survival rate amounting to 75.1±6.4% and 92.5±3.0%, respectively. The index of freedom from acute vascular complications (myocardial infarction, ischaemic stroke) at 5 years in Group One was 54.2±7.2% and in Group Two 86.1±4.3%. Acute vascular complications were causes of lethal outcomes in 13 cases in the group with DM and in 3 cases in the group without DM. Death was most often caused by acute coronary complications. The index of freedom from restenosis at 5 years in Group One amounted to 74.5±8.0% and at 7 years of follow-up in Group Two to 92.3±7.3%. The risk factors for the development of acute vascular complications in diabetic patients according to the findings of the Cox regression analysis were as follows: age above 65 years, DM duration of more than 5 years; the level of glycated haemoglobin above 7.5%; a history of myocardial infarction; presence of degree III arterial hypertension. The risk factors for restenosis included: DM duration of more than 5 years, the level of glycated haemoglobin above 7.5% and presence of degree III arterial hypertension. The results of the study make it possible to regard carotid endarterectomy efficient and safe for both cohorts of patients (with and without DM). In the remote postoperative period, such parameters as survival rate, indices of freedom from acute vascular complications and restenosis turned out to be statistically significantly lower in diabetic patients than in non-diabetic, with the predominating coronary complications induced by insufficient assessment of the coronary reserve and the presence of occult forms of ischaemic heart disease. Long-term results may be improved by means of widening the indications for performing coronarography in patients with DM.

[Assessment of surgical risk in patients with lower limb chronic critical ischaemia]. / Otsenka khirurgicheskogo riska u bol'nykh s khronicheskoi kriticheskoi ishemiei nizhnikh konechnostei.

Analysed herein are both immediate and remote results of surgical treatment of 93 patients presenting with chronic atherosclerotic occlusion of the femoral-popliteal-tibial segment in the stage of critical ischaemia. The patients were subjected to autovenous femoropopliteal bypass grafting to the isolated arterial segment or balloon angioplasty with stenting of the superficial femoral artery. While choosing the method of arterial reconstruction we assessed concomitant diseases, primarily lesions of the coronary and cerebral circulation. In order to objectively evaluate the patient state, we worked out a scale for assessing surgical risk. Survival rate without amputation after three years in patients with low risk amounted to 71.4%, in those with moderate risk to 60.0%, and in high-risk patients to 43.3%. Patients with initially high risk were found to have a high incidence rate of cardiac and cerebrovascular complications, exceeding 40%. It was shown that the worked out system of assessing the level of surgical risk objectively reflects the prognosis of patient survival following a reconstructive operation. This system of assessment may be appropriate while choosing an optimal method of arterial reconstruction (bypassing operation or endovascular intervention) in patients with atherosclerotic lesions of arteries of the femoropopliteal-tibial segment and critical ischaemia accompanied by severe concomitant pathology. Patients with high surgical risk should preferably be subjected to endovascular reconstruction, while those with low surgical risk should better undergo open shunting bypassing operation, and for those with moderate risk it is acceptable to perform both methods of arterial reconstruction.

[Diagnostic peculiarities, surgical policy, and efficacy of reconstructive operations in pathological tortuosity of internal carotid arteries].

We examined a total of 88 patients presenting with unilateral pathological tortuosity of internal carotid arteries (PT ICA), who were subjected to reconstructive interventions. The patients underwent ultrasound duplex scanning of brachiocephalic arteries, CT angiography of the brain, and assessment of cognitive functions according to the Montreal scale (MoCA test). It was proved that absolute indications for operative intervention in patients with pathological tortuosity of ICA comprise coiling, and in kinking - an increase in the linear blood velocity greater than 180 cm/s. Perfusion CT makes it possible to objectively assess the state of blood supply to the cerebral hemispheres. CT angiography of ICAs with 3D reconstruction makes it possible to reveal microaneurysms of the vascular wall in the area of pathological tortuosity. PT leads to deficit of cognitive functions, and performing reconstructive operations improves cognitive functions after 6 months in stage III chronic cerebrovascular insufficiency in 91% of cases, and in stage IV - in 55%.

[Choosing the method of reconstructive operation in patients with atherosclerotic occlusion of the femoral-popliteal-tibial segment in the stage of critical ischaemia]. / Vybor metoda rekonstruktivnoi operatsii u bol'nykh s ateroskleroticheskoi okkliuziei bedrenno-podkolenno-bertsovogo segmenta v stadii kriticheskoi ishemii.

Presented herein are remote results of surgical treatment of 101 patients with atherosclerotic occlusion of the femoral-popliteal-tibial segment in the stage of critical ischaemia. The choice of the reconstructive operation was made based on the developed criteria. Femoral-popliteal shunting into the isolated segment of the reversed great saphenous vein was performed in 48 (47.52%) patients, and 53 (52.48%) patients underwent distal femoraltibial bypass grafting according to the in situ technique. The five-year patency of the graft in these groups was identical, amounting to 54.17 and 58.49%, respectively. In order to predict the duration of bypass graft patency in the isolated segment of the popliteal artery we worked out criteria of competence of the collateral blood flow. We also defined more exactly the indications for applying a relieving arteriovenous fistula in distal femorotibial shunting. When deciding upon a method of operative treatment, preference is given to shunting into the isolated popliteal artery in sufficient collateral blood flow.

[The dynamics of cardio-specified marker troponin I (TN I) as a predictor of acute coronary syndrome under surgery of carotid endarterectomy].

The article deals with the data of dynamics of troponin I as a main marker of damage of myocardium under reconstructive surgery of inner carotid artery. The sampling for randomized prospective clinical examination included 227 patients. It is proved that the indicator of troponin I during the carotid endarterectomy can be used as a marker to evaluate severity of ischemic heart disease and as a predictor of possible development of acute coronary syndrome.

[Tactics of surgical treatment of critical lower limbs ischemia and concomitant coronary heart disease class III-IV].

The possibility and use of prolonged epidural anesthesia in terms of preoperative care was studied in 78 patients. Patients with various stages of coronary arteries affection, central haemodynamics state and risk of reconstructive surgical treatment on lower limb arteries were marked out. Patient selection criteria for aortocoronary shunting or reconstructive operation on great lower limb vessels were worked out. It is proved, that prolonged epidural anesthesia allows not only to attain good analgesia but to minimize cardiac complications at reconstructive operations on abdominal aorta and its branches.

[Choice of optimal surgical reconstruction at patients with critical limb ischemia due to infrainguinal atherosclerotic arterial occlusive disease].

One hundred and four patients with atherosclerotic lesion of femoro-popliteal segment and III-IV stage of ischemia underwent vascular surgical procedures. Results of these operations were analyzed depending on state of distal arterial bed. Autovenous femoro-popliteal bypass (FPB) with reversed autovein was performed at 49 (47.1%) patients, femoro-tibial bypass (FTB) with autovein in situ - at 55 (52.9%). Clinical and angiographic variants of favorable and unfavorable prognosis of FBP and FTB are described. It is demonstrated that severe lesion of outflow distal arteries is the main cause of bypasses thrombosis. Protective arteriovenous fistula in the region of FTB distal anastomosis improves significantly short-term results of operation.

[Auto-venous femoral-popliteal bypass in patients of different age groups]. / Autovenoznoe bedrenno-podkolennoe shuntirovanie u patsientov razlichnykh vozrastnykh grupp.

The results of autovenous femoro-popliteal shunting performed in 106 patients with infrainguinal atherosclerotic arterial occlusion were investigated. All the patients were divided into 3 groups: younger than 50, from 50 to 60 and older than 60 years of age. The most favorable results were registered in the group of patients aged from 50 to 60. In 3 years these results made up 52.2%, in 5 years--17.4%. The lowest indices of shunt functioning were noted in patients younger than 50, and 3 and 5 years later they were 38.5 and 7.7% respectively. In 70% of this age group patients there were injuries of the main crural arteries and significant changes in the phospholipid fraction level. The main cause of unsatisfactory results of shunting operations in the femoro-popliteal area is though to be the injuries of the main crural arteries and the progressing course of the atherosclerotic process.

[Preoperative preparation of patients with critical lower limb ischemia and pronounced painful syndrome]. / Predoperatsionnaia podgotovka bol'nykh s kriticheskoi ishemiei nizhnikh konechnostei i vyrazhennym bolevym sindromom.

Presented herein are the data on the condition of central and cerebral hemodynamics in 98 patients with chronic stage III-IV lower limb ischemia and coexistent CAD as dependent, on the severity of painful syndrome as well as on the necessity of preparing patients at a high surgical risk for reconstructions under prolonged epidural anesthesia. The prognostically dangerous changes in central and cerebral hemodynamics were revealed in persons with severe painful syndrome. In 87% of patients, circulation was hypokinetic. Twenty-six patients with unremovable pain and severe coexistent diseases underwent, as preoperative preparation, prolonged epidural anesthesia. It has been proven that prolonged epidural anesthesia allows to reach not only a good analgetic effect but also to refine the indicators of central and cerebral hemodynamics whereby preventing intra- and postoperative ischemic events.

[Changes in the central and cerebral blood flows of patients with arteriosclerosis obliterans of the arteries of the lower extremities after different types of anesthesia]. / Izmeneniia tsentral'nogo i mozgovogo krovotoka u bol'nykh obliteriruiushchim aterosklerozom arterii nizhnikh konechnostei posle raznykh vidov anestezii.

A comparative analysis of changes in central hemodynamics and cerebral circulation depending on the technique of anesthesia used has been performed in 63 patients after reconstructive surgery on aorto-ileo-femoral segment. Signs of ischemic heart disease have been revealed preoperatively in 40 patients. The majority of them (88%) showed hypokinetic type of hemodynamics. Signs of cerebral atherosclerosis were found in 90% of patients. Rheoencephalographic index in them was lowered by 42%. A statistically significant deterioration in central hemodynamic and cerebral circulation parameters has been recorded immediately after the operation in patients with concomitant ischemic heart disease operated on under general endotracheal anesthesia. An improvement in central hemodynamic parameters after surgery has been observed in the group of patients operated on under epidural anesthesia.

[The late results in the surgical treatment of patients with arteriosclerosis obliterans of the arteries of the lower extremities]. / Otdalennye rezul'taty operativnogo lecheniia bol'nykh obliteriruiushchim aterosklerozom arterii nizhnikh konechnostei.

Long-term outcomes of surgical treatment were examined in 157 patients with atherosclerosis obliterans of lower extremity arteries. Complications of an atherosclerotic process are a basic cause of death in the patients in the long-term postoperative period. More than half (53.7%) the deaths were due to coronary heart disease. In a group of patients in whom coronary heart disease was not diagnosed prior to surgery, death from myocardial infarction was observed in 20.4% of cases during 5 years. Hypokinetic hemodynamics is a poor predictor of survival of patients with lower extremity artery atherosclerotic occlusions.

[Prognosis in the treatment outcome of patients with occlusive atherosclerosis of the arteries of lower extremity arteries by evaluation of lipid metabolism]. / Prognozirovanie rezultatov lecheniia bolnykh s ateroskleroticheskimi okkliuziiami arterii nizhnikh konechnostei po pokazateliam lipidnogo obmena.

The authors discuss the results of correlative analysis of the relative content of the main lipid classes in blood of central and regional venous blood flow with the results of treatment of 75 patients with atherosclerosis obliterans of the lower limb vessels in the stage of collateral circulation decompensation. In patients without anatomo-functional reserves of collateral circulation the amount of phospholipids in the venous blood of the affected limb was found to be significantly lower (by more than 22%) than that in blood collected from the vein in the cubital fossa. This regularity may serve as a criterion for prognosticating the results of treatment of patients in the stage of severe decompensation.

[Hemosorption in the treatment of patients with arteriosclerosis obliterans of the lower extremities]. / Gemosorbtsiia pri lechenii bol'nykh obliteriruiushchim aterosklerozom arterii nizhnikh konechnostei.

Hemosorption results were assessed in 99 patients with obliterating arterial atherosclerosis of the lower extremities. It is demonstrated that extracorporeal systemic detoxication, using different sorbents, is an effective method for improving collateral flow in patients with atherosclerotic occlusions of lower-limb arteries, whose insufficiency of blood transfer pathways is largely functional, and the control of disturbed homeostasis, particularly lipid metabolism and blood rheologic properties.