[Advisability of carotid endarterectomy in asymptomatic patients]. / Tselesoobraznost' karotidnoi endarterektomii u asimptomnykh bol'nykh. Analiticheskii obzor.

OBJECTIVE: To determine the optimal treatment strategy for patients with asymptomatic carotid stenosis. MATERIAL AND METHODS: The authors reviewed clinical guidelines for the management of patients with asymptomatic carotid stenosis 60-99%, as well as medical studies and meta-analyses comparing carotid endarterectomy and optimal drug therapy in asymptomatic patients between 1993 and 2023. RESULTS: The choice of treatment strategy for patients with asymptomatic carotid artery stenosis is still a controversial issue. There were several large randomized clinical trials comparing carotid endarterectomy with optimal medical therapy in asymptomatic patients at the end of the 20th century. However, drug therapy has undergone significant changes calling into question the relevance of previous results. This review highlights the evolution of management of patients with asymptomatic carotid stenosis and also presents modern approaches to the treatment of these patients. CONCLUSION: Patients younger 75 years old gain an advantage from carotid endarterectomy with small perioperative risk compared to optimal drug therapy and yearly risk of cerebral embolism. Patients with asymptomatic carotid stenosis 80-99% are candidates for carotid endarterectomy due to higher risk of acute cerebrovascular accident at least until more data are available. The choice of the best tactics for a particular patient should be made individually depending on own experience and patient's adherence to therapy and lifestyle correction. The results of the ACTRIS (2025) and CREST-2 (2026) studies are expected to clarify this issue.

[Evolution of surgical approaches to carotid bifurcation]. / Evolyutsiya khirurgicheskikh dostupov k bifurkatsii sonnoi arterii.

Carotid endarterectomy is preferable for prevention of acute cerebrovascular accident associated with atherosclerotic lesions of internal carotid artery. Modern interest in minimizing local complications and small excisions is also actual in carotid surgery. The authors review the modern literature data on evolution of carotid arteries exposure. Cutaneous mini-incision, transverse skin incision and retrojugular approach are discussed. The authors consider the advantages and possible complications of each technique.

Long-Term Results of the Treatment of Patients With Chronic Ischemia of the Lower Limbs in Combination With Ischemic Heart Disease.

Aim      To compare long-term outcomes of x-ray endovascular (percutaneous coronary intervention, PCI, and lower limb angioplasty with stent placement, LLA; group 1) and combination treatments (PCI and open LLA surgery; group 2) in patients with chronic lower limb ischemia (CLLI) associated with ischemic heart disease (IHD).Material and methods  This retrospective study has been conducted in the Vishnevsky National Medical Research Center of Surgery since 2019. The study includes 92 patients with stage 2B CLLI associated with IHD who were managed from January 1, 2017 through December 31, 2020. Long-term outcomes were evaluated in 76 (82.6 %) patients. The endpoint was severe cardiovascular complications (CVC), including death, myocardial infarction, and acute cerebrovascular disease (ACVD).Results In group 1 during the long-term period, 1 (2.7%) fatal outcome due to pneumonia was observed. In group 2, 4 (10 %) patients died: 1 (2.5 %) patient due to ACVD, 1 (2.5 %) patient due to progression of oncological process, and 2 2 (5 %) patients due to COVID-19. Also, 2 (5.5 %) and 1 (2.5 %) cases of acute coronary syndrome (ACS) were observed in groups 1 and 2, respectively (p=0.61).Conclusion      In the x-ray endovascular (group1) and the combination (group 2) intervention groups, lethal outcomes due to myocardial infarction were absent. This fact confirms the importance of PCI in patients with CLLI for prevention of possible ACS in the long-term. Both therapeutic tactics in managing CLLI patients with IHD demonstrated high safety and clinical efficacy during the hospital and long-term periods and can be extensively used in routine clinical practice.

[Superior mesenteric artery aneurysm]. / Anevrizma verkhnei bryzheechnoi arterii.

We report surgical treatment of 4 patients with superior mesenteric artery aneurysm. A comprehensive examination including Doppler ultrasound and CT angiography of visceral arteries made it possible to assess the features of vascular anatomy. In accordance with the peculiarities of upper mesenteric artery angioarchitectonics, open and endovascular methods were used. A differentiated approach made it possible to treat patients without any complications.

[Modern conceptions on neck paragangliomas]. / Paragangliomy shei.

Neck paragangliomas are orphan diseases with incidence 1:30 000-1:100 000. Life expectancy is poor in patients with distant metastasis (5-year overall survival 11.8%), whereas 5-year overall survival in patients with regional metastasis is 76.8-82.4%. Meanwhile, there is still no any reliable tool for prediction of malignant potential of paraganglioma. Above-mentioned data indicate an importance of early diagnosis and timely treatment of neck paragangliomas. Total resection of tumor in ablastic conditions is a gold standard of treatment. However, surgery is associated with a high risk of neurovascular complications and requires multidisciplinary approach. Nevertheless, new knowledge dedicated to different aspects of pathogenesis of neck paraganglioma, diagnosis and treatment arise every year. This review is devoted to modern data on neck paragangliomas.

Comparative characteristics of postoperative outcomes of different treatment strategies of patients with intermittent claudication in combination with coronary arteries disease.

Aim      To compare in-hospital outcomes (severe cardiovascular complications, CVC) in patients with IIB stage chronic lower limb ischemia (CLLI) in combination with ischemic heart disease (IHD) in the following groups: stepwise percutaneous coronary intervention (PCI) and stenting and angioplasty of lower limb arteries (LLA) (group 1) and combination treatment, including PCI and open surgery on LLA (group 2).Material and methods  Since 2019, the A.V. Vishnevsky National Medical Research Center of Surgery has performed a retrospective study that includes patients with stage IIB CLLI in combination with IHD. Patients were divided into 2 groups: group 1 (n=46), stepwise X-ray endovascular treatment (PCI and stenting and angioplasty of LLA); group 2 (n=46), stepwise combination treatment (PCI and open surgery on LLA). The endpoint included severe CVCs (death, acute myocardial infarction, acute cerebrovascular disease) and severe complications in the LLA area (stent thrombosis, repeated intervention on LLA, amputation).Results In 198 surgeries, none of 92 patients had severe CVC, and no fatal outcomes were observed. In group 2, there was one (2.1 %) severe complication on LLA during the early postoperative period, for which a successful additional intervention was performed.Conclusion      Individualized approach to care of each patient with LLA pathology in combination with IHD helps avoiding severe CVCs at the hospital stage. It was shown that X-ray endovascular and combination treatments are safe and effective in the absence of fatal outcomes and acute disorders of coronary circulation at the hospital stage.

In Vivo Studies of a Liquid Embolic Compound.

A composition in the form of liquid polymer substance intended for embolization procedures was studied in in vivo experiment. The preparation was injected to rabbits into the femoral artery and abdominal aorta. The polymer composition exhibited properties previously demonstrated in vitro: strong adhesion to the vascular wall, high plasticity sufficient for embolization of the blood vessels, distal distribution, and the absence of toxic effects. The contrast substance remained in the embolus, which simplified its further localization. The agent underwent nether resorption nor organization. Injection of the agent in a volume of 0.1 ml was sufficient for embolization of an artery with a diameter of 0.1 cm. The polymer composition completely obstructed the vessel without inducing perforation of its wall. During the first day of the experiment, a slight infiltration of surrounding tissues with lymphoid cells was observed. By day 7, total dry necrosis of pelvic limb distal to the injection site was diagnosed. Inflammation of the surrounding tissues was shown histologically and was considered as the body response to impaired circulation and necrosis.

[Embolization of the internal iliac artery during endovascular repair of abdominal aortic aneurysms]. / Émbolizatsiia vnutrennei podvzdoshnoi arterii pri éndoprotezirovanii anevrizmy briushnoi aorty.

An abdominal aortic aneurysm is one of frequently encountered cardiovascular diseases, which is often accompanied by an aneurysm of the common and/or internal iliac arteries. Recent trends are towards increased use of endovascular methods of treatment, associated with a certain risk for the development of type IIa endoleaks. This raises the question as to the necessity of embolization of the internal iliac artery while covering it with a stent graft. Our study included a total of 20 patients operated on for abdominal aortic aneurysms combined with aneurysms of the common and/or internal iliac arteries. In order to evaluate the obtained outcomes, the patients were divided into 4 groups depending on the intervention performed. The scope of the performed operations varied from endoprosthetic repair of an abdominal aortic aneurysm with coverage of one internal iliac artery without embolization to endoprosthetic repair of an abdominal aortic aneurysm with coverage of both internal iliac arteries with embolization. In the latter event, two-stage interventions were performed. The duration of follow up amounted to more than 3 years. We assessed the short- and long-term outcomes, with zero lethality and the absence of either specific or non-specific complications observed. Embolization increases the duration of the operation and X-ray exposure, as well as the amount of the contrast medium, thus casting doubt upon the necessity of carrying it out, since the immediate and remote results do not differ as compared with mere coverage of the internal iliac artery.

[Clinical study of efficacy and safety of Aducil in patients with chronic lower limb ischaemia]. / Klinicheskoe issledovanie éffektivnosti i bezopasnosti Adutsila pri khronicheskoi ishemii nizhnikh konechnostei.

AIM: The study was aimed at assessing efficacy and safety of treatment with Aducil® (cilostazol) compared with Trental® 400 in patients with moderate-to-severe intermittent claudication due to peripheral atherosclerosis. PATIENTS AND METHODS: The study included a total of one hundred and forty-five 36-to-75-year-old patients. The participants were distributed into 2 groups according to the inclusion/exclusion criteria in a 2 to 1 proportion: patients in group 1 received Aducil® 100 mg BID, in group 2 - Trental® 400 TID for 12 weeks. 142 subjects completed the protocol. RESULTS: Analysis of the effectiveness of treatment according to the primary criterion showed a better effectiveness of Aducil® as compared with Trental® 400. Subjects who received Aducil® had a higher increase in the absolute maximum walking distance after 12 weeks of treatment as compared with those taking Trental® 400: 126±110 m versus 45±39 m, respectively (р<0.001). Subjects who received Aducil® had a statistically significant improvement in quality of life parameters such as physical and mental health components according to the SF-36 questionnaire after 12 weeks of treatment (р≤0.01). Subjects in Aducil® group had better quality of life with an increase from 34 to 40 points according to the physical component score, while patients in Trental® 400 group demonstrated minor positive changes (from 35 to 37 points); mean mental component score increased from 45 to 48 points in Aducil® group as compared with an increase from 45 to 47 points in Trental® 400 group. While self-reported physical health status was similar between the groups at baseline, subjects in Aducil® group reported better physical functioning after treatment (р=0.016). Two adverse events were registered in two subjects in Aducil® group. CONCLUSION: Analysis of the study endpoints demonstrated that Aducil® had better treatment effectiveness in patients with chronic lower limb ischemia stage IIB according to the classification of A.V. Pokrovsky-Fontaine as compared with Trental® 400, while the safety profile and drug tolerance were similar between the two.

[Biological aspects and clinical application of bone-marrow stem cells in critical lower limb ischaemia]. / Biologicheskie aspekty i klinicheskoe primenenie stvolovykh kletok pri kriticheskoi ishemii nizhnikh konechnostei.

Critical lower-limb ischaemia (CLLI) is associated with high risk of limb loss and a lethal outcome, as well as with decreased quality of life. The underlying cause of the disease is imbalance between blood supply of ischaemized tissues and their metabolic demands. Restoration of adequate perfusion with the help of standard medicamentous therapy or operative treatment is often inefficient or impossible. Cell therapy (CT) is a novel strategy making it possible to stimulate the growth of the microvascular bed and the mechanisms of molecular-cellular repair. One of the most promising trends is the use of bone marrow stem cells (BMSCs). Sufficient evidence concerning safety and relative efficacy of CT has by now been accumulated. The existing differences in the results of studies are related to numerous peculiarities of both CT itself and methods of its application. The present review is dedicated to contemporary notions of the biology of BMSCs, assessment of safety of CT and the results of its application in treatment of CLLI.

[Sulodexide in treatment of chronic venous insufficiency. Results of the All-Russian multicenter programme ACVEDUCT]. / Sulodeksid v lechenii khronicheskoi venoznoi nedostatochnosti. Itogi Vserossiiskoi mul'titsentrovoi programmy ACVEDUCT.

INTRODUCTION: Pharmacotherapy occupies one of the leading places in comprehensive treatment of lower-limb chronic venous diseases (CVD) and their complications. At the same time, there are not so many therapeutic agents intended for treatment of CVD and possessing evidence-based efficacy. Sulodexide (registered in Russia as Vessel Due F) is a drug with a confirmed therapeutic effect in patients with a moderately severe course of chronic venous disease or its late stages. However, the experience of using it in Russia for treatment of patients presenting with initial manifestations of chronic venous insufficiency (CVI) is still scarce. PATIENTS AND METHODS: The data concerning the use of Vessel Due F in the routine practice of treating CVD in Russian patients were collected and assessed within the framework of the ACVEDUCT programme. This observational prospective non-controlled multicentre programme included patients routinely prescribed by their attending physician Vessel Due F as a solution for injections and/or soft capsules in accordance with the registered in the Russian Federation instruction for use. A total of 2,263 patients took part in the programme. RESULTS: The majority of the patients prescribed sulodexide were diagnosed as having CEAP class C3 (38.4%) and class C4 (35.6%) CVD. Treatment was accompanied and followed by a decrease in the symptoms' severity observed in 56.4% of patients and a decrease in the number of symptoms in 42.8% of patients (thus positive dynamics was totally noted in 99.2%), with the effect of taking the drug commencing to manifest itself in patients as early as on day 15-20 of treatment. The highest rate of regression of symptoms of CVD was observed in 30-to-40-year-old patients. A statistically significant positive correlation was revealed between efficacy and the duration of treatment, the use of capsules during the term of follow up, with a negative correlation revealed between efficacy of treatment and the patient's age at which the diagnosis had been made, the stage according the CEAP classification, the total number of symptoms, a combination of risk factors. CONCLUSIONS: Sulodexide proved to be an effective, safe, well-tolerated and pathogenetically substantiated pharmacological agent for treatment of patients presenting with lower-limb CVI and should therefore be recommended for patients at early stages of formation of CVD. Patients suffering from venous trophic ulcers require higher doses and prolonged administration of the drug.

[Endovascular repair of abdominal aortic aneurysm in a patient with transplanted kidney]. / Éndoprotezirovanie anevrizmy briushnoi aorty u bol'nogo s transplantirovannoi pochkoi.

Endovascular repair of the abdominal aorta is a method of choice in pronounced concomitant pathology and high risk of open surgical treatment. The article deals with a clinical case report of successful surgical management of a patient with an infrarenal aortic aneurysm, transplanted kidney, chronic renal insufficiency, secondary diabetes mellitus, multifocal atherosclerosis with predominant involvement of coronary arteries and lower-limb arteries, in whom open surgical treatment was associated with high risk. Endoprosthetic repair of the abdominal aortic aneurysm was performed with a good postoperative outcome.

[Possibilities of hybrid surgery in treatment of thoracoabdominal aneurysms].

The authors present a clinical case report and review of literature concerning treatment of extremely complicated pathology - thoracoabdominal aortic aneurysm, also reflecting the most difficult problems and complications of classical surgical treatment. A successful clinical example showed advantages of a new, less invasive approach, i.e., hybrid surgery. Based on analysing literature sources, the authors describe controversial points of carrying out a hybrid operation and its results. Accumulating experience in and improving technology of the hybrid operation would make it possible to further improve therapeutic outcomes.

[Efficacy of various types of femoropopliteal crural bypass grafting]. / Éffektivnost' razlichnykh vidov bedrenno-podkolenno-bertsovykh shuntirovanii

Over the period from 1997 to 2007 a total of 132 patients presenting with chronic lower-limb ischaemia underwent reconstructive bypass grafting operations performed at the Department of Cardiovascular Surgery of the Murmansk Regional Clinical Hospital named after P.A. Bayandin. Depending on the method of formation of the distal anastomosis the patients were subdivided into two groups: Group I with endarterectomy in the zone of the distal anastomosis, including 39 patients, and Group II without endarterectomy, comprising 93 patients. As the plastic material for bypass grafting we used autoveins in the "reverse" and "in situ" positions, allografts made of polytetrafluoroethylene (PTFE) or woven fabric, combined grafts. In the both groups prevailing were patients with critical ischaemia of the lower limbs. Thus, 20 (51.3%) patients had degree III ischaemia in Group One and 60 (64.5%) patients in Group Two, and 18 (46.2%) patients had ischaemia degree IV and 20 (21.5%), respectively. In order to evaluate the state of the distal bed we calculated the average score according to the Rutherford classification (Rutherford, et al., 1997), which amounted to 7.56 ±1.5 and 6.2±1.43 for Group I and II, respectively. The best patency and limb salvage rate were observed in autovenous bypass grafting according to the "in situ" technique without endarterectomy. Thus, the cumulative patency amounted to 21% and limb salvage to 29.4% after 5 years.

[Endovascular prosthetic repair of abdominal aortic aneurysm combined with crossover femorofemoral bypass grafting].

In pronounced concomitant pathology and high risks of open operative treatment endovascular prosthetic repair of the abdominal aorta is a method of choice. Presented herein is a clinical case report concerning successful surgical treatment of a patient with an aneurysm of the infrarenal portion of the aorta and high risk of open operative treatment. The patient underwent unilateral endovascular prosthetic repair of the abdominal aortic aneurysm and crossover femoro-femoral bypass grafting with a good postoperative outcome.

[Ways to improve patency of the femoral-popliteal-crural bypass grafts].

Chronic obliterating diseases of lower-limb arteries account for more than 20% of all manifestations of cardiovascular pathology. A surgical method of treatment for this pathology remains most effective. The types of operations below the inguinal fold currently used are as follows: bypass grafting, endarterectomy, and angioplasty. The vein is the material of choice and if it is not easily available allografts may be used. Differing elastic properties of the artery and prosthesis lead to progression of the neointima thus negatively affecting patency of bypass grafts. This article describes venous bypass grafts, their efficacy, methods of improving patency of allografts, as well as variants of combined operations.

[Comparative pharmacoeconomic analysis of prostanoids for peripheral arterial occlusive].

Peripheral arteries occlusive disease (PAOD) is a prevalent illness that needs improved pharmacological management, especially for patients not eligible for surgical revascularization. Prostanoids (alprostadil or iloprost) were shown to be effective in PAOD and critical limb ischemia (CLI) but are rather costly. The results of our pharmacoeconomic study (cost estimation based on randomized control trial results) showed that iloprost does not increase cost of treatment when only direct medical costs are taken into account. If indirect costs are included into the analysis iloprost saves up to 27 thousand rubles per patient. Clinical efficacy is still high. Thus iloprost is a better alternative than alprostadil for CLI.

[Administration of the generic prostaglandin E1 VAP 20® in patients with lower limb critical ischaemia: a prospective study].

OBJECTIVE: The study was aimed at assessing efficacy and safety of administering the generic alprostadil VAP in patients presenting with lower limb critical ischaemia. MATERIAL AND METHODS: We carried out a prospective study including a total of 30 patients with lower limb critical ischaemia. The patients' mean age was 67.7±7.8 years, with men predominating - 60%. Trophic ulcers were observed in 40% of patients. The proximal level of the lesion was localized in the arteries below the inguinal ligament in 19 (63.3%) patients, in the aortofemoral segment - in 9 (30%) patients, and in the popliteal-crural-plantar segment - in 2 (6.6%) subjects. The average ankle-brachial index amounted to 0.49±0.4. The studied agent was used at a dose of 40 mcg once a day in patients with stage III ischaemia and a dose of 40 mcg twice daily in patients with stage IV ischaemia. The drug was administered for 14 days followed by a 14-day follow-up period. RESULTS: The pain syndrome score over the 14 days of treatment decreased twofold from 6.1±2.5 to 3.5±2.6 and within the subsequent 14 days it did not increase - 2.4±3.1 (p< 0.05). The number of patients in whom the pain syndrome decreased by 50% amounted to 19 (63.3%). The consumption of analgesic agents decreased from 60% (at the beginning of treatment) to 12 (40%) (14 days after treatment) and to 8 (26.6%) (at the end of the follow-up period). In patients with trophic ulcers, the average size of the ulcers during treatment decreased from 3.3±3.7 cm to 2.8±3.8 after 14 days, and at the end of the follow-up period the size of the ulcers amounted to 2.1±2.8 cm (p >0.05). The number of patients responding to treatment amounted to 22 (77.3%). The ABI during treatment did not change, being 0.49 ± 0.4 at the beginning of treatment, 0.53±0.4 after 14 days of treatment, and 0.47±0.3 at the end of the follow-up period. There were no amputations either during treatment or within the follow-up period. Only one lethal outcome occurred which was related to acute coronary insufficiency. The "response to treatment" was significantly influenced only by the level of the proximal lesion and age (p<0.05). CONCLUSION: VAP 20® demonstrated good efficacy and tolerability comparable to those of the original preparations.

[Endovascular balloon angioplasty of a stenotic lesion of autovenous bypass grafts in the infrainguinal position].

Analysed in the article are the results of dynamic follow up of autovenous bypass grafts in the infrainguinal position. About 80% of patients were operated on for lower limb critical ischaemia. Remote patency of the bypass grafts amounted to 68%. Also presented herein are the outcomes of balloon angioplasty of the bypass grafts (30 interventions) in both immediate and remote periods. Primary success was achieved in 94% of cases. The early stage (30 days) was characterized by two thromboses of the bypass graft, and the remote period showed eleven restenoses. Two limb amputations were performed. The role of endovascular correction of bypass graft stenoses in order to save the limb is determined.

[Own experience endovascular prosthetic repair of abdominal aortic aneurysms].

Endovascular prosthetic repair has increasingly been used over the last several decades. This type of intervention is indicated for patients running a high surgical and anaesthesiological risk of an open surgical procedure. The experience gained in endovascular prosthetic repair of abdominal aortic aneurysms makes it possible to extend the indications for its practical application. The authors describe herein their experience gained in a total of 20 procedures of endovascular prosthetic repair of abdominal aortic aneurysms using the Gore Excluder endograft device in patients running a high risk of an open surgical intervention. There were neither short -nor long-term lethal outcomes. Three patients after endovascular prosthetic repair were found to have type 1 endoleak and two appeared to have type 2 endoleak. Type 1 endoleaks were coped with intraoperationally. Dynamic follow-up (at 1, 6, 12 months after surgery) of patients including computed tomography showed no complications whatsoever (i. e., no endoleaks, endograft migration, nor increase in the aneurysm's diameter). After endografting of abdominal aortic aneurysms there were neither cardiac nor respiratory complications in the immediate postoperative period. Hence, endografting of an abdominal aortic aneurysm is a method of choice for high-risk patients.