[Gas in superior mesenteric artery and celiac axis as a rare CT-sign of extensive bowel necrosis]. / Gaz v verkhnei bryzheechnoi arterii i chrevnom stvole kak redkii KT-priznak obshirnogo nekroza kishechnika.

The authors report endovascular treatment of acute thromboembolic occlusion of superior mesenteric artery in a 75-year-old patient whose postoperative period was complicated by massive reperfusion and translocation syndrome. Contrast-enhanced CT in 12 hours after successful thrombectomy from superior mesenteric artery revealed CT signs of irreversible bowel lesion, i.e. gas in hepatic veins, intestinal wall and mesenteric veins, bowel wall thinning. In addition, CT revealed extremely rare sign of severe acute mesenteric ischemia (gas in superior mesenteric artery and celiac axis). We found no description of gas in celiac axis following acute mesenteric ischemia in available literature.

[Endovascular surgery for acute mesenteric ischemia]. / Éndovaskuliarnaia khirurgiia ostrogo arterial'nogo narusheniia mezenterial'nogo krovoobrashcheniia: podkhody k lecheniiu.

OBJECTIVE: To demonstrate the results of endovascular treatment of 15 patients with acute mesenteric ischemia. MATERIAL AND METHODS: There were 15 patients with acute mesenteric ischemia who underwent surgery (9 men and 6 women). Mean age was 77±11 years. Acute intestinal ischemia was caused by thromboembolism of superior mesenteric artery (9 patients), thrombosis of superior mesenteric artery (5 patients) and critical stenosis of the ostia of superior mesenteric artery and celiac trunk (1 patient). Mean time from clinical manifestation of disease to admission to the hospital was 13 hours (range 2-72 hours). In-hospital development of acute mesenteric ischemia was noted in 2 patients. Indications for endovascular intervention and techniques of endovascular revascularization of superior mesenteric artery are described in the article. RESULTS: Blood flow restoration in superior mesenteric artery was achieved in 14 (93%) out of 15 patients. Laparotomy was required in 4 (27%) patients for extensive resection of necrotic intestine (n=1, 6.7%), local resection of small bowel (n=2, 13%). In another (6.7%) patient, intestine was recognized as viable after laparotomy. A bulk of intestine was preserved in most patients (n=14, 93%). In-hospital mortality rate was 47% (7 patients died). The main cause of nosocomial death (6 cases) was reperfusion syndrome followed by respiratory distress syndrome and multiple organ failure. CONCLUSION: New methods of prevention and treatment of reperfusion syndrome can improve the results of treatment of acute mesenteric ischemia.

[Diagnosis and treatment of extracranial internal carotid artery lesion combined with cerebrovascular malformation]. / Diagnostika i lechenie porazhenii ékstrakranial'nogo otdela vnutrennei sonnoi arterii v sochetanii s sosudistoi mal'formatsiei golovnogo mozga.

AIM: To analyze own experience of diagnosis and treatment of patients with extracranial internal carotid artery lesion and cerebrovascular malformations. MATERIAL AND METHODS: There were 16 patients with combined lesion of extracranial and intracranial internal carotid artery for the period January 2013 - December 2014. Occlusive-stenotic lesion and tortuosity of ICA were observed in 11 and 5 cases respectively. RESULTS: Incidence of combined ICA lesion was 5.2% (16 out of 308 observations of extracranial internal carotid artery lesion). Surgical treatment was performed in 7 patients including two-stage intervention in 4 cases and simultaneous surgery in 3 cases. Mean time between neurosurgical and vascular stages was 6 months. Complications and mortality were absent. CONCLUSION: Two-stage surgical approach with intracerebral vascular malformation correction followed by extracranial ICA reconstruction may be safe and effective in patients with combined lesion of ICA. Further trials are necessary for certain conclusions.

[Early reconstruction of brachiocephalic arteries as a prevention of recurrent ischemic stroke]. / Ranniaia rekonstruktsiia brakhitsefal'nykh arterii kak profilaktika povtornogo ishemicheskogo insul'ta.

AIM: To assess an efficacy and safety of brachiocephalic arteries reconstruction at the acute stage of stroke. MATERIAL AND METHODS: Early reconstruction of brachiocephalic arteries was made in 7 patients (mean age 67±9 years). Mean terms of brachiocephalic arteries reconstruction after stroke were 4.6 days (range 2-7 days). Pre- and postoperative neurological state was assessed by NIHSS score (mean preoperative score was 3.9±2.7 in these 7 patients, range 0-7). All patients had ipsilateral cerebral ischemic lesions with stenosis/occlusion of brachiocephalic artery. Their mean dimension was 10 mm (range 4-32 mm). Internal carotid artery stenting was made in 2 patients, carotid endarterectomy - in 4 patients, stenting of the 1st segment of left subclavian artery - in 1 patient. RESULTS: There were no deaths and recurrent postoperative ischemic strokes. Complications developed in 2 patients: postoperative hematoma and intraoperative transient ischemic attack during ICA stenting in 5 days after stroke. There was a positive course of neurological state after brachiocephalic arteries reconstruction: mean score of neurological deficit decreased by almost 2 times (from 3.9±2.7 to 2±1.7). CONCLUSION: Early surgical prevention (within 7 days after stroke) may be effective and safe in certain patients with ischemic stroke (neurological deficit by Rankin score ≤3 and NIHSS ≤7, ischemic focus dimension less than 4 cm). Brachiocephalic arteries reconstruction early after stroke improves neurological state postoperatively by reducing motor and sensitive disorders. However, at present time there are no clear indications for early revascularization depending on either neurological deficit severity and ischemic focus dimension. So, our data should be confirmed by large trials.

[Early reconstruction of supra-aortic vessels as a prevention of recurrent ischemic stroke]. / Rannyaya revaskulyarizatsiya golovnogo mozga kak profilaktika povtornogo ishemicheskogo insul'ta.

AIM: To evaluate the efficacy and safety of supra-aortic vessels reconstruction within acute period of stroke. MATERIAL AND METHODS: Early surgery was performed in 7 patients aged 67±9 years. Revascularization was made after 4.6 days after ischemic stroke on the average (range from 2 to 7 days). Neurological status before and after surgery was assessed using NIHSS scale, mean preoperative score was 3.9±2.7 (0-7). All patients had ischemic brain lesions (4-32 mm, mean 10 mm) unilateral with carotid stenosis or occlusion. Carotid artery stenting was performed in 2 patients, carotid endarterectomy - in 4 patients and stenting of segment I of the left subclavian artery was made in 1 case. RESULTS: There were no mortality and recurrent postoperative ischemic stroke. Complications occurred in two patients: postoperative hematoma and intraoperative transient ischemic attack that developed during CAS after 5 days of a stroke. There was positive neurological dynamics after revascularization: there was almost 2-fold decrease of mean score of neurological deficit (from 3.9±2.7±1.7 to 2). CONCLUSION: Early surgical prevention of recurrent stroke (up to 7 days) can be performed effectively and safely in carefully selected patients with ischemic stroke (neurological deficit less than 3 Rankin scores and less than 7 NIHSS scores, ischemic lesion dimensions lass than 4 cm). Reconstruction of supra-aortic vessels in acute stage of stroke improves the neurological status and reduces the degree of motor and sensory disorders. However, currently there are no clear criteria for inclusion and exclusion of patients for early revascularization using both degree of neurological deficit and size of ischemic lesion. So our results need to be confirmed by large trials.

[Endovascular interventions for acute ischemia of intestine].

It is presented 5 clinical observations of acute ischemia of intestine in which different endovascular interventions including isolated superior mesenteric artery stenting, rheolytic and aspiration thrombectomy and combination of techniques were applied. Surgical success with blood flow restoration in superior mesenteric artery was achieved in 4 of 5 patients. 2 patients have required laparotomy and intestinal resection. In 1 case extent of resection was significantly reduced after previous endovascular thrombectomy. There were no deaths. It is concluded that endovascular interventions may be considered as independent method of treatment of patients with acute mesenteric ischemia.

[Experience in diagnosis and treatment of combined lesions of the extra- and intracranial portions of the internal carotid artery].

The treatment policy concerning patients with lesions of the extra- and intracranial portions of carotid arteries is currently uncertain. The authors share herein their experience in diagnosis and treatment of 5 patients presenting with lesions of the extracranial portions of the internal carotid artery (stenosis/occlusion/pathological tortuosity) combined with arterial aneurysms and arteriovenous malformations of the brain. Of these, two patients were operated on: the first one was primarily subjected to clipping of the cerebral aneurysm then after several months underwent a reconstructive vascular operation on the ipsilateral side (resection of the internal carotid artery with its readdressing). The second patient with subtotal stenosis of the internal carotid artery who initially underwent clipping of the ipsilateral asymptomatic aneurysm of the middle cerebral artery developed occlusion of the internal carotid artery by the second stage of treatment and was not subjected to vascular operation. There were no is-chaemic cerebral complications or lethal outcomes in the operated patients in peri- and post-operative periods at all stages of treatment.

[Modern approach to diagnosis and treatment of acute mesenteric ischemia].

It was proposed the medical and diagnostic tactic in patients with acute mesenteric ischemia on basis of efficiency results of modern laboratory markers and instrumental methods. Positive laboratory D-dimer-test with computed tomography of abdominal organs or abdominal aorta and its branches CT-angiography led to diagnose thrombosis or embolism of mesenteric arteries at early terms and to reduce preoperative period. The authors presented the variant of isolated endovascular intervention in case of superior mesenteric artery thrombosis. This technique may be regarded as the method of choice in the treatment of patients with acute mesenteric ischemia.

[Venous thromboembolic complications in patients with intracranial hemorrhage and tumors of the central nervous system].

It was analyzed the results of diagnosis and prevention of venous thromboembolic complications in 248 patients with intracranial hemorrhages of different etiology (hemorrhagic stroke, subarachnoid hemorrhage, craniocerebral injury, hemorrhages in the tumors of brain and spinal cord). The overall frequency of venous thrombosis in the vessels of the inferior vena cava pool was 24.6% (in 61 patients), the majority of patients had the asymptomatic thrombosis. The crural veins were the main localization of venous thrombosis. Also it was the main origin of thromboembolic complications (60.7%). Surgical treatment in different amount was an independent predictor of venous thromboembolic complications in neurosurgical patients according to the multivariate variance analysis. The frequency of thrombosis was significantly higher in the group of operated patients in comparison with non-operated group (37.1 vs. 17.6% (p=0.008). Early prevention by geparin (the use of direct anticoagulants for 2-4-th day of the founding of an intracranial hematoma) did not reduce the frequency of venous thrombosis in operated patients, but significantly reduced the frequency of fatal pulmonary embolism: 0 vs. 9.1% (p=0.002). Patients with intracranial hemorrhage are the one of the most unfavorable groups in terms of their venous thromboembolic complications.

[Sural sinus as the main source of postoperative venous thromboembolic complications in neurosurgical patients].

The authors analysed the results of diagnosis and treatment of venous thromboembolic complications in a total of 239 patients presenting with various-aetiology intracranial haemorrhage and tumours of the central system. The total incidence of venous thromboses in the system of the inferior vena cava amounted to 25.1%. Thromboembolism of pulmonary artery complicated the course of the underlying disease in 3.3% of cases. Operative treatment of the underlying disease resulted in an increased incidence rate of thromboses of deep veins from 18.5 to 36.4% (p=0.015) and that of pulmonary artery thromboembolism from 2.7 to 4.5% (p=0.5). The most frequently encountered localization of thromboses in the postoperative period turned out to be the sural veins of the crus. The level of consciousness (p=0.0001), operative treatment (p=0.002), putaminal and thalamic intracranial haematomas (p=0.01), as well as dislocation syndrome (p=0.05) according to the findings of the univariate analysis were the risk factors for the development of venous thromboses in patients with haemorrhagic stroke. Independent predictors of the development of venous thromboembolic complications in patients with haemorrhagic-type acute impairments of cerebral circulation according to the data of the univariate analysis were the level of consciousness by the Glasgow coma scale scoring 4-5 points (p=0.01) and deep-seated localization of the intracerebral haematoma (p=0.01). Patients with intracranial haematoma having endured operative treatment are a cohort of patients running the highest risk for the development of postoperative venous thromboembolic complications.

[The possibilities of laser Doppler flowmetry for the estimation of the intestine resection volume by the acute mesenteric ischemia].

The results of the surgical treatment of the acute mesenteric ischemia in 2 groups of patients were comparatively analyzed. The control group (n=52) experienced the traditional way and criteria of detecting the volume of intestinal resection (color and peristaltic activity, arterial pulsation). For the main group (n=57) the intraoperative estimation of the intestinal viability was performed with the help of laser Doppler flowmetry. As a result, the postoperative intestinal gangrene rate was 9.1% among patients of the main group, whereas the complication was registered among 48.6% of the control group. The main group of patients demonstrated the overall lower rate of postoperative complications in comparison with the control group: 67.6 and 40.9% (p=0.01), respectively. The same picture was for the lethality rate: 76.9 and 52.6% (p=0.03), respectively.

[Safety and efficacy of various regimens of heparin-mediated prevention of venous thromboses in patients with intracranial haemorrhage].

Analysed in the article is the incidence rate of the development of venous thromboembolic complications in a total of 79 patients presenting with various-aetiology intracranial haemorrhage in different regimens of heparin-mediated prevention. The authors have revealed that early (on day 2-4 after the onset of the disease) administration of preventive doses of heparin in patients with intracerebral and intracranial haematomas is a safe and efficient regimen, since it decreases the rate of venous thromboses in the system of the vena cava inferior and fatal thromboembolic complications as compared with a later term (on day 5 and more) of initiating heparin-mediated prevention.

[Major intestinal resections and short-bowel syndrome in patients with the acute mesenterial thrombosis].

The study represents the retrospective analysis of major intestinal resections (the length of the left in olace bowel less then 200 sm) and non-major resections in 52 patients operated on the acute mesenterial thrombosis. Major bowel resection was performed in 30 patients (57.7%). 66.7% of those patients (20 of 30) died soon after the operation. Whereas lethality rate among patients with non-major resections was 54.5% (12 of 22). All 10 survived patients demonstrated the short-bowel syndrome during the follow-up period (the median follow-up time was 25 months).

[Intestinal microcirculation in health and in acute impairment of mesenteric blood flow].

The authors attempted to determine instrumental criteria for vitality and non-vitality of the intestine with the help of laser Doppler flowmetry and absorption spectroscopy. The material used was subdivided into two study groups: in group one, the indices of microcirculation of the viable small and large intestine were determined during elective cavitary operations; group two comprised 20 portions of resected necrotised segments of the large and small intestine, wherein we registered the indices of microcirculation of the non-viable devitalized intestine. We thus obtained instrumental indices of microcirculation of various intestinal portions in health, as well as in the setting of acute impairment of intestinal blood circulation and intestinal gangrene. Statistically significant differences were revealed only for the parameter of microcirculation and the coefficient of variation of the "viable" and necrotized intestine; blood oxygen saturation and volumetric blood filling of tissue between the two groups did not differ significantly. The instrumental criteria for intestinal vitality and non-vitality of may be used while making a decision as to the scorife of resection of the intestine affected which would thus make it possible to decrease the rate of progression of intestinal necrosis in the postoperative period. We believe that this would make it possible to substantially improve the outcomes of surgical management and to decrease lethality in patients presenting with acute impairment of mesenteric circulation.