[Surgical treatment of an aneurysm of the deep femoral artery].

We report herein a rare clinical case concerning an isolated deep aneurysm of the femoral artery with extravasal compression of the superficial femoral vein, complicated by venous insufficiency and oedema of the lower extremity. A 66-year-old female patient was admitted complaining of a pulsing formation on the left inguinal region, a feeling of puffiness and heaviness of the left lower extremity. The findings of the ultrasonographic Doppler scanning showed no signs of deep veins thrombosis, however, in the projection of the Skarpovsky's triangle of the left lower limb, there was an aneurysmatic dilatation of the deep femoral artery, arteriovenous malformation (?). In order to specify the diagnosis, we performed multispiral CT angiography revealing an isolated aneurysm of the deep femoral artery. Therefore, we carried out successful resection of the aneurysm with the end-to-side reimplantation of the unaltered distal portion of the deep femoral artery into the superficial femoral artery. Preoperative multispiral CT angiography is a valuable non-invasive diagnostic tool serving to evaluate not only an aneurysm itself but the distal arterial bed.

[Surgical treatment of varicosity-altered tributaries of saphenous veins].

A total of 469 patients presenting with lower-limb varicose disease were operated on at Municipal Clinical Hospital No 79 of the Chair of Hospital Surgery No 2 of the I.M. Sechenov First Moscow State Medical University over the period from 2008 to 2011. The tributaries of varicose veins were removed by means of miniphlebectomy according to the Muller technique, the Narat technique, with the use of a cryoprobe and an original-design vein extractor. The main method of removing tributaries is currently miniphlebectomy by the Muller technique. However, removal of the tributaries over 10 mm in diameter by the Muller s technique was associated with a skin tear in the site of the puncture, which healed with the formation of a hypertrophic scar. Miniphlebectomy of tributaries measuring less than 10 mm in diameter with the signs of previously endured phlebitis is accompanied, as a rule, by a rupture of the venous wall in the form of phlebosclerosis and a commissural process with the underlying cellular tissue. Phlebectomy by the Narat s technique was predominantly performed for removal of short tributaries from the altered paravasal cellular tissue. The method of cryophlebectomy was used by means of intravasal or paravasal insertion of the probe. A vein extractor was used to remove the tributaries form the altered cellular tissue at a distance of up to 20 cm. The choice of an optimal method of treatment for varicosity-altered tributaries makes it possible to decrease the complications rate and to obtain good cosmetic outcomes.

[Modern methods of comprehensive management of patients with varicose disease relapsing after surgical interventions].

Despite progress achieved by Russian phlebology in diagnosis and treatment of lower-limb varicose disease, the latter remains the most commonly encountered pathology of the vascular bed. Treatment for varicose disease includes a series of unsolved as yet problems, the main of which being a relapse of varicose disease after surgical interventions. The authors share herein their experience gained in using comprehensive methods while managing varicose disease relapses, also describing the technique of the procedures performed and analysing certain technical variants thereof.

[Minimally invasive methods for the treatment of the recurrent varicosis].

The experience of 193 cases of recurrent variceal disease (RVD) was summarized. Major reasons of recurrences after surgery were analyzed. Traditional and miniinvasive RVD treatment approaches are listed and its efficacy was thoroughly analyzed. Thus, endovasal laser coagulation and phleboscleroobliteration of insufficient communicant veins were effective in 85% and 65% of RVD, respectively. Possibilities of cryophleboextraction as well as apparate phlebectomy with transillumination were described.

[Cell technologies in complex treatment of venous trophic ulcers].

Live skin equivalent and fibroblasts in gel were used in complex treatment of venous trophic ulcers to evaluate efficacy of cell transplants. Their efficacy depended on extent of trophic ulcer and time of their existence. Cell culture method is minimally traumatic, can be used in elder patients and seniors and gives positive results in 85% of cases.

[Diagnostics and treatment of pulmonary embolism in patients with floating thrombus of the infrainguinal area].

The results of management of 25 patients with floating thrombus of the deep infrainguinal veins were analyzed in the article. The US scanning proved to be enough for the reliable diagnostics of the disease. The surgical management of the category of patients was considered to be the mainstay of the pulmonary embolism prophylaxis.

[Minimally invasive interventions in surgical management of varicose diseases and its relapses].

Over the past several decades, many surgical methods of treatment for varicose disease have been implemented into clinical practice. Nonetheless, an intrinsically too traumatic nature thereof unsatisfactory cosmetic outcomes obtained, long-term postoperative rehabilitation required, and high recurrence rates reported send us in search of minimally invasive but at the same time highly efficient methods of treatment for varicose disease. The present article deals with the experience gained by Russian and foreign authors in and suggesting efficiency of novel minimally invasive technologies used for treatment of both newly diagnosed varicose disease and its relapsing forms. This is followed by analysing different variants of the procedural techniques involved.

[Outcomes of surgical management of patients with thromboses of the superficial and deep venous system].

Presented herein are the outcomes of examination, surgical management and conservative treatment of 211patients presenting with phlebothromboses of the superficial and deep venous system of the lower limbs. Of these, 119 were treated conservatively and 92 underwent various types of surgical intervention, however those treated conservatively were not included into the final analysis. The diagnosis was verified using ultrasonographic duplex scanning (USDS) of the venous system of the inferior vena cava basin, allowing of assessing the condition of the superficial and deep venous system of the both lower extremities, followed by determining the length of the thrombotic lesion. Based on the findings of USDS, 68 (74%) patients were found to have thrombosis of the superficial veins and 24 (26%) subjects were diagnosed with deep-vein thrombosis. All the patients in order to prevent thromboembolic complications were subjected to active surgical policy. Also studied were methods of surgical management in patients with various-localization thromboses. Based on the obtained findings, it was determined that surgical treatment of patients with thromboses of the superficial and deep venous system of the lower limbs is a justified method to prevent the development of pulmonary thromboembolism.

[Surgical treatment of the acute thrombosis of superficial veins].

Treatment results of 53 patients with acute thrombosis of superficial veins are presented. Carrying-out of radical one-stage cross-ectomy with combined phlebectomy in the saphena magna system at the height of inflammation period is proposed. Radical one-stage cross-ectomy with phlebectomy in case of phlebothrombosis gives good therapeutic effect, improves the status of a patient. Given treatment mode allows to reduce the period of temporary disability and rehospitalization in order to move off the trunk and inflows left after cross-ectomy.

[Errors in examination and management of patients with lower limb varicosity and their role in development of a relapse of the disease].

Analyzing the literature of the recent years and own clinical experience gained in management of patients diagnosed with recurrent varicose disease indicate that along with the progression of the disease one of the main causes of its relapses are certain medical errors leading to the development of relapsing varicosity of the lower limb veins. Moreover, the number of medical errors often appears to considerably exceed the total number of the patients in whom they were revealed, i. e., several and more medical errors would have been made sequentially in one and the same patient at various stages of the examination. The present work is based on the findings obtained from a comprehensive examination and comparative analysis of the condition of the patients presenting with recurrent varicosity of the veins of the lower extremities, and the errors we revealed to have been made during the prior examination and surgical treatment of the latter. The errors were subdivided into diagnostic, tactical, technical and organizational ones as follows: Diagnostic errors: missed in 195 (90%) patients at the moment of the primary examination turned out to have been incompetent perforating veins, in 82 (38 %) -saphenopopliteal reflux, and in 12 (5.5 %) patients not revealed turned out to have been the signs of postthrombotic disease, dysplasia of venous valves and arteriovenous fistulas. Tactical errors: in 61 (28 %) patients exceeded had been the indications for sclerotherapy, in 39 (18 %) - the indications for ligature methods, and 95 (44 %) patients were found to have had the trunk of the smaller saphenous vein not removed during the primary intervention. Technical errors: in 115 (53 %) patients we revealed a long stump of the greater saphenous vein and in 156 (72 %) that of the smaller saphenous vein, also left had been the trunk of the GSV in 43 (20 %) patients, and in 141 (65 %) subjects revealed were errors in treatment of the perforating veins of the crus and femur or a complete absence thereof. Our experience and the literature data indicate that the greatest number of complications, unfavourable therapeutic outcomes, and relapses of varicose disease occur during the management of phlebological patients in general surgical departments, with the attending physicians having insufficient training in phlebology. In our opinion, this quite delicate intervention should be performed by vascular surgeons, or surgeons duly trained in this specific modality.

[Combined therapy of lower limb variceal disease].

Complex surgical and medical therapy was used for 386 patients with lower limb variceal disease 2nd and 3rd form (segmental and disseminated varices with reflux through the superficial and perforant veins) and chronic venous insufficiency stage I (according to the Russian classification). Five main types of surgical interventions were fulfilled: combined phlebectomy, trunk scleroobliteration, short stripping with insufficient perforants ligation, short stripping with excision or damage of variceal influx, and short stripping with trunk scleroobliteration. Besides, vast majority of patients received venotonic drug Phlebodia 600 pre and postoperatively. Miniinvasive and atraumatic interventions were characterized by the decrease of postoperative subcutaneous hematomas, no incidence of n. saphenus damage and lymphorrhea, good cosmetic outcomes due to the absence of additional incisions. The duration of postoperative recovery correlated with intraoperative trauma and Phlebodia 600 administration. In conclusion, combination of complex surgical procedures and venotonic drugs can be widely used for the management of lower limb variceal disease, especially for its uncomplicated forms. While preserving the radicality, these interventions yield favorite esthetical results, reduce the time of postoperative recovery and disability, thus, appear to be cost effective.

[State of the greater saphenous vein following intraoperative truncal scleroobliteration in varicose disease].

The authors have analyzed the outcomes of intraoperative truncal scleroobliteration of the greater saphenous vein, which was used instead of stripping in patients presenting with varicose disease of the lower limbs. Obtained were three variants of the condition of the vessel concerned following the intervention: complete obliteration, preserved lumen, and alternating portions of obliteration and patency. It was determined that varicosity of saphenous veins and incompetent perforating vein of Dodd were more often encountered in preserved patency of the trunk of the greater saphenous vein on the femur, which required additional treatment. Tested were methods of non-surgical correction of the surgical outcomes by means of echosclerotherapy.

[Surgical treatment of initial forms of varicose veins of the lower extremities].

Experience in the treatment of 386 patients with stage 2-3 of varicose disease is analyzed. There are five main variants of surgical treatment in these patients: combined phlebectomy, sclero-obliteration of the trunk, short stripping with ligation of insufficient perforant veins, short stripping with excision or destruction of varicose branches, short stripping and sclero-obliteration of the trunk. It is demonstrated that minimally invasive surgical procedures decrease the number of postoperative subcutaneous haematomas, ensure good cosmetic effect, allow to avoid an injury of n.saphenus and lymphorrhea. It is concluded that minimally invasive surgical procedures may be used for treatment of initial forms of varicose disease.

[Comparison of variceal surgery methods]. / Sravnitel'naia otsenka metodov khirurgicheskogo lecheniia varikoznoi bolezni.

Combined ablation of great saphenous vein (GSV) remains the most common way of lower limb variceal management. In recent years different surgical methods were proposed for the treatment of varices. Nevertheless, their invasiveness, poor esthetic outcome, prolonged postoperative rehabilitation and recurrences cail for the development of new minimally invasive and highly effective methods. In the last 5 years a new procedure of intraoperative trunk catheter scieroobliteration of GSV and its tributaries was introduced. From 1997 to 2002 total 493 surgical corrections of lower limb varices were fulfilled, among them 374 patients were operated for primary variceal vein dilatations including 188 standard combined venectomies (1st group) and 186 trunk obliterations (2nd group). Groups were similar in age, sex and lesion extension. Outcomes were followed up to 4 weeks - 5 years. Outcomes comparison between groups has demonstrated significantly lower incidence of postoperative subcutaneous hematomas in the 2nd group, absence of saphenous nerve injuries, better esthetics in the absence of additional incisions (remaining variceal tributaries were sclerosed postoperatively by puncture scieroobliteration). Besides postoperative rehabilitation period was double shorter in ihe 2nd group then in the 1st one. Recurrence rate in long-term period was similar in both groups. Thus intraoperative trunk scieroobliteration of GSV can be a valuable alternative for standard combined venectomy.

[Bilateral malignant carotid chemodectoma]. / Zlokachestvennaia dvustoronniaia karotidnaia khemodektoma.

A clinical case of carotid chemodectoma is reported. Unique character of this case consists in combination of rare manifestations of this disease in a patient (malignancy, bilateral location). Summarizing their own experience and analysis of literature data the authors give recommendations for diagnosis and management of such patients.