[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.

[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.

[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.

[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.

[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.

[Treatment of abdominal aortic aneurysms in patients older than 70 years of age].

The investigation has shown that patients with the diagnosed abdominal aortic aneurysms must be operated, the age being not considered a contraindication to surgical treatment. Five years survival of the patients after resection of the abdominal aortic aneurysm and its prosthesis does not depend on the age and is higher than 70%, while the expectant management leads to rupture of the aneurysm and death of 70% of the patients. A medical algorithm has been developed allowing reduction of lethality of elderly patients with abdominal aortic aneurysms and less frequency of complications.

[Semiclosed endarterectomy of the aorto-femoral segment by Vollmar loops]. / Poluzakrytaia éndarteréktomiia aortobedrennogo segmenta petliami Vollmar.

In 1996-1998 131 patients were observed who underwent semiclosed loop endarterectomy of the aorto-femoral segment by Vollmar loops. The control group consisted of 220 patients on whom the operations of uni- or bilateral aorto-femoral bypass with synthetic prostheses were made. The semiclosed loop endarterectomy was mainly fulfilled through the femoral access, the retroperitoneal access was used in 18.3% of the patients. Thus the time of operation was as short as (100 +/- 10.9) min. in mono- and (118.6 +/- 12.9) min. in bilateral reconstructions, and blood loss in typical cases was not more than (327 +/- 24.1) ml. The operation of semiclosed loop endarterectomy gave a high level of patency to the reconstructed aorto-femoral segment. The primary 5-year patency of the iliac arteries was 91.86%, the cumulative one--93.87%. Such parameters for shunting operations were lower: 75.4 and 81.63% respectively (p < 0.05).

[An assessment of the efficacy of intravenous monotherapy with the preparation solcoseryl in patients with arteriosclerosis obliterans of the vessels of the lower extremities]. / Otsenka éffektivnosti vnutrivennoi monoterapii preparatom "Solkoseril" u bol'nykh s obliteriruiushchim aterosklerozom sosudov nizhnikh konechnostei.

The authors share their experiences with using Solcoseryl in treatment of 158 patients with obliterating atherosclerosis of the lower extremity vessels. This treatment was found to be very effective. A scheme of the treatment is proposed after which the improved quality of life retains during not less than 6 months in 93% of the patients. The accessory maintenance therapy with minimum doses of aspirin and nicotinic acid is enough between the courses of treatment with Solcoseryl.

[The surgical treatment of aneurysms of the abdominal aorta]. / Khirurgicheskoe lechenie anevrizm briushnoi aorty.

Based on an experience with treatment of 107 patients with aneurysms of the abdominal aorta subjected to planned or urgent operations the authors discuss the problems of the clinical course, diagnosis, indications for operative treatment, the technique of operative interventions and their results. In planned operations lethality was 4.1%, in ruptures of the aneurysm-64.2%. One year after the operations 90% of the patients were practically healthy, 5 years later they were 70%.