[Operations of revascularization in surgery of cerebrovascular aneurysms].

Surgical revascularization of the brain is one of the most important trends in the development of neurosurgery. Restoration of adequate blood flow through pre- and intracerebral arteries promotes prevention and treatment of ischaemic lesions of the brain in various pathology. The present work was aimed at analysing the experience gained in performing revascularizing operations in patients with cerebral aneurysms at the department of neurosurgery. The authors analysed therapeutic outcomes in a total of 45 patients presenting with giant and complex aneurysms of cerebral arteries and treated from 2009 to 2014. Of the 45 patients with giant and complex aneurysms of cerebral arteries, 31 (68.8%) patients underwent open microsurgical interventions (including 10 patients with the use of different variants of revascularizing operation) and 14 (31.2%) patients were subjected to endovascular exclusion of the aneurysm from the blood flow. It was shown that performing revascularizing operations in patients with complex and giant aneurysms of cerebral arteries makes it possible to compensate circulation in the interested arterial basin and to obtain good functional results.

[Extracorporeal reconstruction of arteries of a transplant of the liver for its subsequent implantation and surgical aspects of arterial anatomy the hepatoduodenal area].

Orthotopic liver transplantation (OLT) remains the only and radical method of treating patients with terminal stages of chronic diffuse hepatic diseases (cirrhoses), of patients with various congenital metabolic lesions of the liver, autoimmune diseases characterized by lesions of bile ducts, as well as series of both primary and secondary tumorous hepatic lesions. Liver transplantation is one of the most complicated operative interventions. Difficulty of OLT is determined by multifactorial and well-coordinated work of various medical services at the pre-, intra- and postoperative stage of management. One of the important components of success in transplantation consists in providing adequate arterial blood flow of the transplanted organ, which is achieved by extracorporeal reconstruction of the transplant. Variants of arterial blood supply of the liver are observed in each third donor. These anatomical peculiarities increase probability of a surgical error, which is considerably higher if not taking into consideration the complicated anatomy of the donor organ and its misalignment with the anatomical peculiarities of the recipient. Surgeon's responsibility is especially great during taking out the liver from the donor, as well as during its preparation for implantation. Procurement of the liver and pancreas from the same donor for transplantation to two different recipients may be accompanied and followed by the so-called conflict of interests which the surgeon has to decide in favour of the both during procurement of the organ for its extracorporeal processing. The sequence of the presented surgical manipulations on hepatic and pancreatic vessels, as well as anatomical reference points make it possible to preserve the vessels of the maximum length for the both organs. A wide variety of the structure of hepatic vessels may be divided into three types, depending upon the number of the sources of arterial blood supply.

[Aneurysm of abdominal aorta resulting in vertebral body destruction. Simultaneous prosthetic repair of aorta bifurcation and anterior lumbar fusion with mesh implant].

This case report describes unique situation of dissecting aneurysm of aorta resulting in L3 vertebral body destruction. Diagnostic work-up that helped to elicit proper diagnosis and surgical management is described. Clinical and neuroimaging results of treatment, as well as detailed literature review are given.

[Determining surgical policy in combined atherosclerotic lesion of carotid arteries in patients with uncomplicated aortic aneurysm].

Presented herein are the outcomes of managing a total of twenty-six patients suffering from an uncomplicated abdominal aorta aneurysm with a concomitant atherosclerotic lesion of the coronary arteries, referred to our Clinic over the period form 2003 to 2006. Of these, nineteen (70%) patients were diagnosed with the first (symptom-free) stage of cerebral ischaemic disease, and six presented with the second stage [to have endured a transient ischaemic attack (TIA) within the terms from 16 to 3 months prior to admission]. Two patients had residual events of the previously sustained acute cerebral ischaemia (ACI) (stage 4). The current stage ofischaemic cerebral disease was determined according to the classification of A. V. Pokrovskii (1979). The haemodynamically significant stenoses of carotid arteries (over 70%) were revealed in five patients, an aneurysm of the internal carotid artery - in one patient, and eighteen patients were presenting with the degree of carotid arteries stenosis varying from 30 to 60% (of these, in two subjects after previously endured TIA, the plaque was heterogeneous and defined as embolism-threatening). No atherosclerotic lesions of the carotid artery were revealed in two patients, though these patients had previously sustained an AIA with the preserved neurological deficit by the moment of examination. Eight patients underwent reconstruction of the internal carotid arteries. The average age amounted to 64.5 years. Al of the eight operated on patients with a combination of ischaemic cerebral disease and an aneurysm of the abdominal aorta were found to have had no neurological complications either after the first, or after the second operations. The devised algorithm of examination and surgical management for patients presenting with an abdominal aorta aneurysm and a combined lesion of the brachiocephalic arteries made it possible to reduce the rate of neurological complication from 4.3% to 1.3%.

[Experience in treating embologenic thromboses of deep veins of lower extremities].

The present work deals with analysing the outcomes of surgical management carried out in a total of five hundred and sixty-six patients diagnosed as having embologenic thrombosis of the lower-limb deep veins. Of these, 377patients received a cava filter implanted, with the remaining 189 patients being subjected to thrombectomy from the iliac and femoral veins. In nineteen patients, the operation was supplemented by establishing an arteriovenous fistula. The decision of whether or not to perform a surgical intervention in patients presenting with thrombosis of deep veins of the lower extremities was made based on the type and pattern of the thrombus concerned. First of all, such surgery was indicated primarily for those diagnosed with a floating, embolus-hazardous thrombus. Thrombectomy was carried out in the patients with a favourable prognosis of the underlying disease, if activation of the pathological process was possible. Cava filters were implanted to the patients diagnosed as having a recurrent embolism, with an unfavourable prognosis of the course of the underlying disease, as well as to those presenting with a severe concomitant pathology. Ultrasonography-guided control is obligatory at all stages of management.

[Clinical and ultrasound diagnostics of acute venous thrombosis].

The results of clinical and ultrasound diagnostics of acute venous lower limbs thrombosis in 206 patients are analyzed. The patients were divided in two groups; those in the first group (n=96) had a diagnosed pulmonary embolism, patients of the second (n=110) had no signs of it. 37 (18%) patients had an asymptomatic course of venous thrombosis, 25 (68%) of those were diagnosed with pulmonary embolism. 154 (74%) patients had floating thrombs, which resulted in pulmonary embolism in 53%. Clinical and ultrasound criteria of embologenic venous trombosis are developed. It allows prognose the pulmonary embolism development and optimize the treatment tactics.

[Abdominal aorta ruptured aneurysm in patients with previously endured endovascular grafting for aortic aneurysm: clinical case reports].

The article deals with four reports of rarely encountered clinical cases, i. e., a ruptured aneurysm of the abdominal aorta in patients having previously sustained endovascular grafting of the abdominal aorta for the pathology concerned. The incidence rate of such complications we faced for the first time in 2001 has ever since amounted to 1.6 % of the total number of patients with a ruptured aneurysm admitted to our Department over the period form 2001 to 2006 (250 patients). All the patients were emergently operated on, with the lethality rate amounting to 50 % (two of the four patients died). The time having elapsed from the primary operation (endovascular grafting of the abdominal aorta aneurysm) till the rupture ranged from 11 days to 3 years.

[Temporary hemostasis in the injuries of great vessels of different location].

Temporary hemostasis is one of the main points in emergency surgery of patients with trauma of major vessels. Folley catheters were used for temporary hemostasis in bleedings from stab-cut wounds with a narrow wound canal. The method of temporary clamping of the abdominal aorta above the visceral branches during profuse abdominal bleedings of unknown etiology is described in detail.

[Flap transverse sternotomy during operations on the vessels and organs of the upper mediastinum and the first cervical zone].

A surgical approach to vessels and organs of the upper mediastinum was grounded, developed and tested. An experimental study of flap transverse sternotomy was carried out in 20 cadavers. A wide approach with throwing of the presternum was the best for manipulations in proximal parts of the aortic branches. This approach was also less traumatic.

[Interrelationship between platelet nitric oxide production and plasma fibrinogen level in emergencies].

Platelet nitric oxide production has been investigated in patients with thoracic and abdominal wounds, thermal trauma, varicose disease, methanol and leponex poisoning. There is correlation between absolute platelets nitric oxide production and fibrinogen plasma level in these patients. The maximal absolute platelets nitric oxide production has been revealed at surgical diseases, and minimal has been observed at methanol poisoning. Irrespectively to etiology and danger of disease, reliable correlation between absolute platelets nitric oxide production and fibrinogen plasma level of these patients is established. Consequently platelets nitric oxide production may be important for haemostatic processes.

[The efficacy of surgical and conservative methods in secondary prevention of carotid ischemic stroke].

A comparative analysis of the efficacy of surgical and conservative methods in secondary prevention of carotid ischemic stroke has been conducted in patients with clinical symptoms of acute ischemic brain lesions (carotid artery stenosis less than 70%). The results of the 3-year follow-up study revealed that carotid endarterectomua is a method of choice. Comparing to conservative therapy, it allows a reduction of the absolute risk of secondary ischemic episode development to 4% (57% for conservative therapy) and of the relative risk--to 0.07 (0.77 for conservative therapy). The necessity of antiaggregate therapy that enables increased percentage of strokes prevented is proved. Comparing to aspirin, clopidogrel is a drug of choice contributing to the regress of thrombotic layers in the cases of restenosis development in the area of sutures after the interventions using special patches.

[Prolonged endarterectomy in distal forms of arterial diseases of the lower extremities]. / Protiazhnaia endarterektomiia pri distal'nykh formakh porazheniia arterii nizhnikh konechnostei.

Six-year experience of surgical treatment of patients with critical lower limb ischemia due to a distal form of arterial lesion is presented. Surgical treatment was performed in extended occlusive lesion from inguinal fold to arteries of the calf and foot, and inadequate "ways of outflow". The king of arterial lesion did not permit the surgeon to perform typical bypass surgery or arterialisation of venous system with a traditional scheme. All the patients were candidates for amputation. For salvage of extremity 36 patients underwent prolonged semi-closed endarterectomy using special instrument which was supplemented with temporary arterio-venous fistula or popliteal-distal auto-venous bypass. In short-term period after surgery critical ischemia was eliminated in 25 (69%) patients. The rest of the patients underwent amputations. 5 years later cumulative safety of the extremities was 95% among patients with good short-term results. These variants of revascularizing surgery may be regarded as alternative to amputations in patients with critical limb ischemia due to distal lesions of lower limbs arteries.

[Surgical management of vertebral artery injuries].

The authors describe problems of giving urgent surgical care to patients with wounds of the vertebral arteries in different areas of the neck and propose a simple and reliable method of hemostasis for wounds of the vertebral artery in the bony canal. An analysis of results of the surgical treatment of 16 patients with injured vertebral artery is presented.

The treatment of patients with injury to the great arteries of the lower extremities.

This paper analyzes the results of the treatment of 92 patients with injury to the great arteries of the lower limbs, which accounted for 15.9% of the number of all patients with injury to the great vessels. As regards lower limb ischemia, the patients were distributed in the following way: 15 (16%) patients had degree I, 27 (29%) degree IIA and 50 (55%) had degree IIB-IIIA ischemia (according to the classification of acute ischemia by I. I. Zatevakhin). All casualties with arterial trauma of the lower limbs were operated on. In the postoperative period, the patients were administered conservative therapy using anticoagulants, spasmolytics, and antiplatelet agents. Intraarterial infusion therapy, detoxification techniques and HBO therapy were applied. Good and satisfactory results were obtained in 78 (80.5%) patients; amputations were performed in 10 (10.8%) patients. The lethality constituted 8.7% (n=8). The authors hold that early hospitalization to the multi-discipline continuous medical institutions forms the basis for refinement of the treatment results in patients with injury to the great arteries of the lower limbs.

Formation of a genuine aneurysm of the vein graft 16 years after femoropopliteal bypass grafting.

Presented herein is a case of vein graft aneurysm formation 16 years after femoropopliteal bypass grafting using the reverse autogenous vein.

[Surgical treatment of patients with arrhosive bleedings undergone reconstructive surgeries on the aorta and lower limbs arteries]. / Khirurgicheskoe lechenie bol'nykh s arrozivnymi krovotecheniiami posle rekonstruktivnykh operatsii na aorte i arteriiakh nizhnikh konechnostei.

Results of surgical treatment of 25 patients with arrhosive bleedings were analyzed. All of them had functioning shunts and severe infectious complications of the wounds in the region of Scarp's triangle. Infected wounds existed from 15 days to 18 months. Bleeding from the wound of Scarp's triangle was seen in 96% cases (24). Insufficiency of distal anastomosis due to arrhosia was in 15 patients (60%). Arrhosive bleeding from anastomosis of the synthetic graft with aorta or common iliac arteries was in 8 (32%) cases, insufficiency of distal anastomosis of femoral-tibial bypass was seen in 2 (8%) patients. Various extrafocal surgeries are method of choice in the treatment of arrhosive bleedings. These surgeries may be performed simultaneously (at first bypass, then removing of graft) or during 2-3 stages in lengthy purulent-inflammatory process.

[The nature of a relationship of nitric oxide with angiotensin-converting enzyme and malonic dialdehyde in patients with atherogenic stenosis of the internal carotid artery]. / Kharakter vzaimosviazi oksida azota s antiotenzinprevrashchaiushchim fermentom i malonovym dial'degidom u bol'nykh s aterogennym stenozom vnutrennei sonnoi arterii.

In patients with stenosis of the internal carotid artery (ICA), a relationship was studied between the level of nitric oxide (NO) and the activity of angiotensin-conversing enzyme (ACE) and malonic dialdehyde (MDA) in the blood serum taken from: 1) the cubital vein an hour before carotid endarterectomy; 2) ICA before surgery; 3) the internal jugular vein before surgery; 4) ICA 5 min after surgery; 5) the internal jugular vein 5 min after surgery; 6) the cubital vein an hour following surgery. There was a direct correlation between the level of NO and the activity of ACE and an inverse correlation between the content of NO and MDA in the sera taken from the cubital, internal jugular vein, and ICA before and after endarterectomy. There were significant increases in the level of NO, in the activity of ACE, and in the content of MDA and total cholesterol in the serum taken from the cubital vein before carotid endarterectomy, which is indicative of significant oxidative stress and the necessity of its pathogenetic correction.

[Surgical treatment of ruptured abdominal aortic aneurysm]. / Khirurgicheskoe lechenie bol'nykh s razryvom anevrizmy briushnoi aorty.

Over the last 30 years more than 1000 patients with abdominal aortic aneurysms (AAA) were treated. Results of treatment of 367 patients with disruption of AAA from 1989 to 2002 were analyzed. Elderly and old patients account for 92% (338) of them. In 61% (224) patients after aneurysm's disruption blood outflew into the retroperitoneal space, in 23.4% (86) - into abdominal cavity, in 13,1% (48) patients retroperitoneal hematoma and hemoperitoneum formed, 2% (7) were the patients with functioning aorto-caval fistula, in 0.5% (2) aneurysm disrupted into the duodenum. There was no surgery due to different causes in 161 patients, all these patients died. One hundred and sixty-five patients underwent surgery, lethality was 60% (99 patients). Linear grafting of the aorta or aorto-iliac grafting was performed in the majority of patients - 77 (46.7%). Based on the obtained data three types of clinical picture of AAA disruption are devined: fulminant, acute and sub-acute. Complex treatment improved results of the treatment: lethality from 1989 to 1996 was 71.6%, from 1997 to 2002 - 52%.

[The simultaneous operation for rectal cancer and abdominal aortic aneurysm]. / Simul'tannaia operatsiia po povodu raka priamoi kishki i anevryzmy briushnogo otdela aorty.

The authors present a successful case of simultaneous operation for rectal cancer and abdominal aortic aneurysm.

[Bypass surgeries from remote vascular beds in the treatment of critical limb ischemia in elderly and old patients]. / Operatsii shuntirovaniia iz otdalennykh sosudistykh basseinov v lechenii kriticheskoi ishemii nizhnikh konechnostei u bol'nykh pozhilogo i starcheskogo vozrasta.

The problem of surgical treatment of elderly and old patients with critical limb ischemia and severe concomitant diseases is discussed. Surgical bypass from remote vascular beds is the only real possibility of effective care for such patients with the lowest risk. The results of treatment of 90 patients with critical limb ischemia were analyzed. The surgical technique is described in details. Modified methods of proximal anastomosis creation and technology of safe installation of graft into subcutaneous canal in subclavial-femoral bypass, surgical technique in femoral-femoral and ileo-femoral cross-over bypass are also described. Results demonstrate high efficacy of these surgeries and their lower risk. It is concluded that improved surgical technique permits to expand indications for surgery in elderly and old patients and to improve immediate and long-term results.