Use of polymethylmethacrylate in treatment of arteriovenous angiodysplasia with bone lesions.

Arteriovenous dysplasia is rather uncommon disease, quite often leading to severe complications even in young age. Involvement of the osseous apparatus into the pathological process is frequently associated with the problem of amputation of the affected limb. Therefore, salvage of the extremity while removing arteriovenous shunt and trophic impairments is an extremely important clinical task. In the presented herein clinical case report, a female patient with arteriovenous angiodysplasia of the lower limb with the tibial bone involved into the pathological process underwent repeated stagewise embolisations, failing however to achieve complete liquidation of the arteriovenous reflux. In this connection, after removal of angiomatous tissues, requiring also excochleation of the damaged portions of the bone, in order to reinforce the axis of the tibial bone the intramedullary canal of the latter was filled with polymethylmethacrylate (PMMA). Expansion of the spectrum of auxiliary methods, besides the most frequently performed in such patients embolisations of afferent arteries and removal of angiomatous tissues would make it possible to increase radical nature of interventions with salvage of the supporting function of limbs.

[Endovascular treatment of post-traumatic arteriovenous fistulae].

AIM: To summarize the experience of endovascular treatment of traumatic arteriovenous fistulae. MATERIAL AND METHODS: Endovascular interventions for arteriovenous fistulae of different locations were applied in 16 patients aged 19 to 83 years (mean 50.4±14.3) in A.V. Vishnevskiy Institute of Surgery from 2003 to 2014. Among causes there were stab wounds, gunshot wounds, blunt trauma, iatrogenic. Different endovascular methods including stenting with self-opening and balloon-expanding stent-grafts, embolic coils and occluders implantation were used. RESULTS: Pain syndrome, disorders of support function and trophic changes were observed in patients with arteriovenous fistulae more localized more distal than lower one third of the thigh. More proximally located arteriovenous fistulae regardless of their diameter resulted severe heart failure and portal hypertension. Angiographic and clinical success was achieved in 100% of cases. Manifestations of heart failure and portal hypertension disappeared in all patients after endovascular interventions. Also support function restored, pain and trophic disorders were cured. CONCLUSION: Arteriovenous fistulae regardless of their size, location and time of existence must be dissociated. Prolonged arteriovenous shunting leads to severe heart failure. Current technologies and tools used in endovascular interventions provide reliable dissociation of arteriovenous fistulae even in case of difficult anatomical features.

[Angiodysplasias of the head and neck: present-day principles of treatment using elements of plastic surgery].

The authors assessed the outcomes of treatment of fifty-one patients presenting with angiodysplasias of the head and neck. Of these, 24 patients suffered from the venous form and 27 had the arteriovenous form. The 51 patients accounted for 23.5% of the total number of patients with congenital vascular malformations over a five-year period. The topicity and angioarchitectonics of the lesion were specified by means of the standard diagnostic complex (i. e., duplex scanning of the vessels, ultrasonographic study of the soft tissues and osseous structures, computed and magnetic resonance tomography, echocardiography, and angiography). Radical excision of the angiomatous tissues was performed in 15 patients and palliative one - in 36 cases. Eight patients were subjected to stagewise resection interventions, ten patients underwent stagewise sessions of laser coagulation, and seven patients endured stagewise roentgenoendovascular embolisations of the afferent arteries. Two patients with the venous form were postoperatively subjected to sessions of sclerotherapy of the residual venous caverns. Two patients in the remote period (7-10 days) underwent autodermoplasty with a free perforated cutaneous flap. This technique was used while closing the wound surface after removing the angiomatous tissues of the parotid region and hairy portion of the head. In five patients the wound surface was closed with a mobilized cervical fat-cutaneous flap. Taking into consideration the importance of the cosmetic outcome after excising the angiomatous tissues on the face and neck, it is necessary to seek for wide application of plastic methods of closing the wound. These methods simultaneously allow of making operative interventions for angiodysplasias more radical.

[Current trends in diagnosis and treatment of arteriovenous angiodysplasia].

A total of 240 patients with arteriovenous angiodysplasia (AVD) were examined and treated in A.V. Vishnevsky Institute of Surgery during 1997-2009. Embolization was performed in 196 (81.7%) patients. Staged embolization was the principal treatment modality in 84 (35%) patients presenting with inoperable lesions. The mean number of sessions was 3.6. Intraoperative embolization using hydrogel embols, Gianturco coils, and 96% alcohol was done in 17 (7.1%) patients. Radical surgery with the removal of angiomatous tissues was given to 33 (13.8%) patients. Palliative resections were made in patients with extensive lesions and impossibility of total removal of angiomatous tissues. Minor and major amputations were needed in 15 patients. It is concluded that intervention for microfistulous and confined macrofistulous lesions should be performed only in case of absolute indications for surgery. That in asymptomatic or subclinical cases is justified only for minor surface lesions fit for radical resection. Minor amputation is indicated in certain patients with arteriovenous fistulas on distal limb segments. Extensive delayed resections should be planned with the use of plastic surgical techniques (autodermoplasty using free flaps, mobilized flaps, and flaps with microvascular anastomosis).

[New aspects in diagnosis and treatment of obliterating thromboangiitis (Buerger disease)].

The nature of arterial occlusive lesions in young smokers is an object of continuous debate commencing from 1879 when Winiwarter for the first time described a vascular syndrome which he called «obliterating endarteritis¼. However, in 1908 Buerger published his works hav.' lg become classical and then his monograph (1924) dedicated to this disease for which he used a new name «obliterating thromboangiitis¼ which further on became a generally accepted term. Diagnosis of obliterating thromboangiitis was made very often in the past. The occurrence of this disease is considerably lower nowadays than 20 or 30 years ago; therefore, the last 10-15 years have witnessed no publication of serious works on this subject. It should be underlined that obliterating thromboangiitis is an independent disease differing fundamentally from atherosclerosis with considerably less frequent occurrence.

[Angiodysplasias: role of mediators and growth factors].

The review of the literature deals with the findings concerning the role of impaired interaction between the basic angiogenic mediators and growth factors in vascular malformations. Presented herein are the contemporaneous views opinions on the aetiology and pathogenesis of angiodysplasias.

[Mediator interactions in vasculogenesis and angiogenesis].

The article contains a review of the literature dedicated to the problems concerning mediator interactions in vasculogenesis and angiogenesis. Also presented herein is the role of the key angiogenic mediators and growth factors in the processes concerned, as well as certain variants of vasculo- and angiogenesis impairments associated with mediators dysfunction discussed.

Renal artery stenosis: incidence of detection during angiography in patients with peripheral arterial disease.

The purpose of this study was to determine the frequency with which atherosclerotic lesions of renal arteries are detected during diagnostic angiography in patients presenting with peripheral arterial disease. To this was added the assessment of the risk factors for the development of atherosclerotic renal artery lesions (i. e., gender, age, and the level of a concomitant lesion of the lower-limb arteries). The findings obtained in our study revealed that each fourth patient with Leriche's syndrome appeared to have a significant lesion of the renal artery. Female sex was found to be a predictor of renal artery lesions in patients with peripheral arterial disease. Patients presenting with pathology of renal arteries proved significantly older than those having no lesions of renal arteries.

[Transcutaneous laser coagulation in treatment of venous forms of angiodysplasias].

Presented herein is the authors'experience with transcutaneous laser coagulation (TLC) used for treatment of various-localization venous angiodysplasias in a total of twenty-one patients. Also described are the issues concerning the methodology involved and the course of the operational procedure. The main criteria used while analysing the outcomes of TLC were the clinical patterns and the findings of duplex scanning. Good to satisfactory results were eventually observed in 71.4% of the patients. Based on the outcomes obtained after TLC, the authors worked out the principles of appropriate practical application of laser-mediated technologies in patients presenting with venous angiodysplasias.

[Aneurysm of the popliteal vein. Review of the literature and a case report].

The article deals with a brief review of the literature dedicated to rather an uncommonly encountered pathology of the major veins, i. e., an aneurysm of the popliteal vein. Described herein are variants of the clinical pattern and possible complications, with an emphasis placed on methods of diagnosis and differential diagnosis of tumour-like neoplasms in the infragenicular region. Also presented is a clinical case report of successful treatment of a female patient diagnosed with a popliteal vein aneurysm.

[Femoro-popliteal bypass above popliteal fossa with PTFE graft: which graft diameter is better?].

The paper presents the results of 80 femoro-popliteal bypasses above popliteal fossa for patients with lower limb atherosclerotic lesions that were fulfilled with the use of polytetrafluoroethylene (PTFE) graft in the Department of Vascular Surgery, AV Vishnevsky Institute of Surgery, from February 1992 till December 2005. 50% of patients had lower limb ischemia grade IIb, 13.7% - grade III and 36.3% - grade IV. Distal circulation was good in 41.2%, satisfactory - in 48.5% and unsatisfactory - in 10.3% of patients. The technique of surgical reconstruction was conventional. In 50% of cases the diameter of PTFE grafts was 8 mm, in another 50% - 6 mm. A statistically significant difference in bypass patency was revealed between prostheses with different diameter in late postoperative period. For the 8-mm grafts the patency rate was 93%, 64% and 51% in 12, 30 and 60 months, respectively, while for the 6-mm grafts the same rate was 62%, 44% and 31%, respectively (p=0.004).

Arterialization of the hand venous system in patients with critical ischemia and thrombangiitis obliterans.

The lesion of distal arteries in patients with thrombangiitis obliterans happened to looking for nondirect methods of blood supply improvement of the involved limb - transplantation of omental pedicle, arterialization of veins, thoracic sympathectomy, etc. From 1986 in the Department of vascular surgery of A. V. Vishnevsky Institute of Surgery we use method of arterialization of the venous system in patients with critical lower limb ischemia of differ etiology. Practically at the same time we applied this operation for patients with critical upper limb ischemia and thrombangiitis obliterans. In this paper we present our successful experience of 5 operations - arterialization of the hand venous system in 4 patients with thrombangiitis obliterans and critical upper limb ischemia. We reviewed in details the technique of performance of arterialization of the hand venous system and studied the long-term results of the treatment.

[Long-term outcomes of femoropopliteal bypass above the knee-joint fissure by means of vascular prosthesis <> in patients with atherosclerotic lesions of lower limb arteries].

Presented herein are the remote results of a total of 110 operations of femoropopliteal shunting above the knee-joint fissure, carried out using the vascular: prosthesis <> in patients diagnosed with atherosclerotic lesions of arteries of the lower limbs over the period between November 1995 and December 2005 at the Department of Vascular Surgery of the A. V. Vishnevsky Institute of Surgery of the Russian Academy of: Medical Sciences. The operative interventions were carried out according to the conventionally accepted technique. Fifty-four (49.1%) patients were operated on for grade II B ischemia, 26 (23.6%) suffered from grade III ischaemia, and 30 (27,3%) subjects were found to have grade IV ischaemia. The average age of the patients was 60.2+/- 7.4 years. The mean values of the ankle-brachial index (ABI) along the posterior greater femoral artery (PGFA) and the anterior greater femoral artery (AGFA) in patients presenting with grade II B ischaemia amounted to 0.52+/-0.21 and 0.55+/-0.15, respectively. In patients with critical ischaemia, the respective ABI values equalled 0,37+/-0,23 and 0.4+/-0.22 Studying the state of the distal bed showed that the condition of the outflow tracts was <> in 54.3% of patients, being defined as <> in 37%, and as <> in 8,7%. The total duration of the long-term follow-up period amounted to: 100 months, averaging 28.4+/-19.5 months. The main clinical factors determining the remote: patency of the vascular prostheses <> in the femoropopliteal position were as follows; the values of the outflow score, the diameter of the popliteal artery, and the ankle-brachial index after surgery. With <> outflow tracts, the patency of the transplants after 3 years amounted to 57%., after 5 years being 48%. In cases of <> outflow tracts, the patency of the vascular prostheses 3 years, after surgery amounted to 26%. In <> outflow tracts, none of the bypasses remained passable for more than 12 months (P<0.01). The dependence between the value of the lumen of the popliteal artery and the patency of the vascular prosthesis was observed to be persisting during the first 2 years following fiurnory, In patients with arterial lumen <3 mm, the patency after 6. 12 and 18 months amounted to 61%, 47% and 41%, respectively; with the popliteal artery's lumen equalling 3.5 mm and more, the patency amounted to 77%, 63%, 42% and 86%, 68% and 56%, respectively, at the above-mentioned time intervals (P<0.05). When the value of the ABI following surgery was >1, the patency of the vascular prostheses after 60 months amounted to 41%, with the ABI>1, after 50 months, the patency amounted to 17%. With the ABI<0.9, none of the shunts remained patent for more than 31 months (P<0.05). Using the pattern of prediction of the outcomes of the femoropopliteal shunting by means of the vascular prosthesis <> above the knee-joint fissure, with due regard for the condition of the distal vascular bed the value of the lumen of the popliteal artery and the value of the ABI after surgery made it possible to rather reliably predict the patency of the prosthesis in the remote terms after surgery (P<0.01).

[Lower limb venous angiodysplasia as a cause of chronic venous insufficiency: specific diagnosis and treatment].

The paper presents a current understanding of chronic venous insufficiency that develops in venous forms of dysplasia. Management of venous dysplasia must be based on multidisciplinary approach including comprehensive diagnosis (predominantly noninvasive), integrative surgical and non-surgical treatment. Modern therapy must be complex and carried out in highly specialized facilities. Best functional and esthetic results can be achieved only through combined therapy. When surgical or non-surgical interventions are inappropriate or impossible, management focus must be placed on clinical control of vascular anomaly (follow-up and compression-based conservative treatment) aimed at minimization of its unfavorable impact on vital functions and at quality of life improvement.

[Femoropopliteal bypass above the knee-joint fissure by means of a vascular prosthesis made of PTFE: choosing an appropriate diameter of the prosthesis].

Presented herein are the outcomes of a total of 80 operations of femoropopliteal grafting above the knee-joint fissure, carried out using a vascular prosthesis made of polytetrafluoroethylene (PTFE) in patients diagnosed with atherosclerotic lesions of the arteries of the lower extremities over the period between February 1995 and December 2005 at the Department of Vascular Surgery of the A. V. Vishnevsky Institute of Surgery of the Russian Academy of Medical Sciences. Fifty percent of the patients were operated on for grade II B ischemia, while 13.7% of the patients suffered from grade III ischaemia of the lower limb, and 29 (36.3%) subjects were found to have grade IV ischaemia. The condition of the distal bed was considered <> in 41.2% of the patients, being defined as <> in 48.5%, and as "poor" in 10.3%. The operative intervention was carried out according to the conventionally accepted technique. 50% of the reconstructions were performed using the prosthesis 8 mm in diameter, and 50% - using that measuring 6 mm in diameter. A statistically significant impact of the diameter of the prosthesis used on the patency of the graft in the remote postoperative period was revealed: with the prosthesis 8-mm in diameter, the patency after 12, 30 and 60 months amounted to 93%, 64% and 51%, respectively, while with the transplant measuring 6 mm in diameter, these indices at the above-mentioned time intervals did not exceed 62%, 44% and 31%, respectively (P=0.004).

[The role of laser doppler flowmetry in the assessment of microcirculatory disturbances at angiodysplasias].

The paper presents the data on the use of laser Doppler flowmetry (LDF) for microcirculation assessment in patients with lower limb angiodysplasias. Preliminary results suggest that LDF can be successfully used both for the quantification of microcirculatory disturbances and for the diagnosis of arterio-venous micro fistulas. LDF was used as a monitoring tool for compressive therapy effectiveness in patients with arterio-venous and venous forms of lower limb angiodysplasias. Compression stockings Relaxsan III class were shown to improve microcirculation in this patient population after 1 month wearing.

[The use of Alprostan for patients with intermittent claudication].

Total 50 patients with lower limb intermittent claudication (Fontain-Pokrovsky limb stage of chronic ischemia) due to femoropopliteal or ileofemoral atherosclerotic occlusion were treated with Alprostan (Prostaglandin El) in A.V. Vishnevsky Institute of Surgery, Moscow, from November 2003 to March 2005. The paper presents the analysis of drug's therapeutic effectiveness dependent on the level and severity of arterial lesion.

[The peculiarities of diagnosis and treatment of chronic venous insufficiency and venous forms of lower extremity dysplasia].

The authors present the modern viewpoint concerning the problem of chronic venous insufficiency in the cases of venous forms of dysplasia. The treatment of patients with of venous forms of dysplasia should be based on the principles of interdisciplinary approach, which stipulates both the careful diagnosis on the basis of mainly non-invasive methods and integration of surgical and conservative treatment methods. Today such treatment should be combined and conducted within the multi-purpose highly specialized institution. Only the combination of all treatment methods will allow achieving the best functional and esthetic results. In the cases when indications are absent and conduction of surgical or any other treatment method is impossible it is necessary control the venous anomaly (dynamical follow-up, compression as a basic variant of conservative therapy). It will allow minimizing the unfavorable influence on vital functions and improving the patient's life quality.

[Present-day classifications of congenital vascular malformations (angiodysplasias)].

The article deals with the previously existing classifications of congenital vascular developmental abnormalities (angiodysplasias,malformations), with an emphasis put on the main classificatory features, as well as on the basic differences between angiodysplasias and haemangiomas. Due coverage is given to specifying certain problems related to the apparently synonymous technical terms and words widely used in the clinical practice concerned. Also, carefully described herein are two most frequently occurring in the practice of cardiovascular surgery classifications of dysplasias, namely that of Hamburg, and V.N. Dan's classification with a close look at the strengths and weaknesses thereof.