[Does an attempt to save a limb always prolong the patient's life?] / Vsegda li popytka sokhranit' konechnost' prodlevaet zhizn' patsienta?

AIM: The purpose of the study was to examine overall survival and the incidence of major adverse cardiovascular events, as well as economic expenditures for treatment of patients with occlusion of the femoropopliteal-tibial segment and critical ischaemia in low competence of the outflow channel, with a poor prognosis for endovascular or open revascularization of lower-limb arteries. PATIENTS AND METHODS: We studied the results of treating a total of 68 patients with lower-limb critical ischaemia and low parameters of the outflow channel competence. Primary arterial reconstruction was performed in 48 cases. At various terms after revascularization due to thrombosis of the reconstruction zone and the development of gangrene, amputation of the lower limb was performed: at 3 to 11 (n=25) and at 12 to 24 (n=25) months. Primary amputation of the lower limb was performed in 20 patients. The endpoints of the study included overall survival, the incidence of major adverse cardiovascular events, and economic expenditures for the in-hospital treatment. The average duration of follow-up amounted to 2 years. RESULTS: The obtained findings demonstrated that in patients with lower-limb critical ischaemia and low parameters of the outflow channel competence, redo arterial reconstructions and amputation within 11 months, as well as a high level of surgical risk were associated with a low overall survival rate and the development of major adverse cardiovascular events in the remote period. Secondary surgical interventions on the major vessels significantly increased the cost of treatment.

[Outcomes of revascularizing operations on lower-limb arteries in patients with critical ischaemia and multifocal atherosclerosis]. / Iskhody revaskuliariziruiushchikh operatsii na arteriiakh nizhnikh konechnostei u bol'nykh s kriticheskoi ishemiei i mul'tifokal'nym aterosklerozom.

The purpose of this study was to evaluate the amputation-free survival rate and predictors of major adverse cardiovascular events (extracardiac and cardiac mortality, non-fatal myocardial infarction, non-fatal stroke) in patients with atherosclerotic occlusive-stenotic lesions of the femoropopliteal-tibial segment and critical ischaemia. We analysed the results of treating a total of 122 patients with atherosclerotic lesions of the superficial femoral artery and lower limb critical ischaemia. Of these, 35 patients had no lesions of other arterial basins, 24 patients presented with a concomitant lesion of the carotid basin, 41 subjects had lesions of the coronary basin, and 22 had lesions of the coronary and carotid basins. The patients were subjected to either bypass graft operation (n=75) or endovascular intervention (n=47). The evaluated outcome measures were amputation-free survival and the frequency of major adverse cardiovascular events. The average duration of follow up amounted to 38.2±4.3 months. The carried out multivariate logistic regression analysis demonstrated that the factors associated with lower limb amputation and the development of major adverse cardiovascular events were as follows: a concomitant lesion of the coronary (p=0.044) and coronary-carotid (p<0.05) basins, a history of endured myocardial infarction (p=0.003), a C-reactive protein level not less than 17.0 mg/l (p<0.05) and the value of the apolipoprotein B/A1 ratio above 1.0 (p=0.004).

[Antithrombotic therapy after bypass grafting below the inguinal ligament]. / Antitromboticheskaia terapiia posle shuntirovaniia nizhe pakhovoi sviazki.

The importance of antithrombotic therapy following reconstructive operations on arteries below the inguinal ligament is beyond question. The pharmaceutical market offers a wide variety of antiaggregant and anticoagulant agents, with many studies (including randomised and multicenter ones) performed worldwide on the problem of choosing optimal antithrombotic therapy in the postoperative period after arterial reconstructions. Nevertheless, the problem of selecting adequate antithrombotic therapy after shunting operations remains undetermined. Presented in the article is a review of foreign studies on the problem concerned. This is followed by discussing the results of many large international studies, including such trials as the BOA and CASPAR. Based on the findings obtained in these studies, Cochrane reviews, European and American guidelines, the authors express their opinion on the algorithms of choosing an appropriate variant of antithrombotic therapy during the postoperative period in patients after arterial reconstructions below the inguinal ligament.

[Assessment of surgical risk in patients with lower limb chronic critical ischaemia]. / Otsenka khirurgicheskogo riska u bol'nykh s khronicheskoi kriticheskoi ishemiei nizhnikh konechnostei.

Analysed herein are both immediate and remote results of surgical treatment of 93 patients presenting with chronic atherosclerotic occlusion of the femoral-popliteal-tibial segment in the stage of critical ischaemia. The patients were subjected to autovenous femoropopliteal bypass grafting to the isolated arterial segment or balloon angioplasty with stenting of the superficial femoral artery. While choosing the method of arterial reconstruction we assessed concomitant diseases, primarily lesions of the coronary and cerebral circulation. In order to objectively evaluate the patient state, we worked out a scale for assessing surgical risk. Survival rate without amputation after three years in patients with low risk amounted to 71.4%, in those with moderate risk to 60.0%, and in high-risk patients to 43.3%. Patients with initially high risk were found to have a high incidence rate of cardiac and cerebrovascular complications, exceeding 40%. It was shown that the worked out system of assessing the level of surgical risk objectively reflects the prognosis of patient survival following a reconstructive operation. This system of assessment may be appropriate while choosing an optimal method of arterial reconstruction (bypassing operation or endovascular intervention) in patients with atherosclerotic lesions of arteries of the femoropopliteal-tibial segment and critical ischaemia accompanied by severe concomitant pathology. Patients with high surgical risk should preferably be subjected to endovascular reconstruction, while those with low surgical risk should better undergo open shunting bypassing operation, and for those with moderate risk it is acceptable to perform both methods of arterial reconstruction.

[Choosing the method of reconstruction for lower-limb critical ischemia].

Presented herein are long-term outcomes of surgical treatment of 74 patients with atherosclerotic occlusive-stenotic lesions of the femoral-popliteal-tibial segment and critical ischaemia. 51 (68.92%) patients underwent femoropopliteal shunting into the isolated segment of the reversed great saphenous vein. Of these, three patients were subjected to a hybrid operation consisting of femoropopliteal bypass grafting and balloon angioplasty of the popliteal and one tibial artery. 23 (31.08%) patients endured percutaneous balloon angioplasty with stenting of the superficial femoral artery and balloon angioplasty of one tibial artery. Two-year patency of the zone of reconstruction of the femoropopliteal segment in these groups was identical, amounting to 64.71 and 56.52%, respectively. However, the group of patients with endovascular intervention demonstrated rather a high rate of intraoperative complications--21.74%, technical success in balloon angioplasty of arteries of the crus amounted to 65.22%. Once the method of operative treatment is chosen, preference is given to shunting in the isolated popliteal artery with sufficient collateral blood flow. Further studies are required to determine angiographic indications for endovascular intervention on tibial arteries.

[Choosing the method of reconstructive operation in patients with atherosclerotic occlusion of the femoral-popliteal-tibial segment in the stage of critical ischaemia]. / Vybor metoda rekonstruktivnoi operatsii u bol'nykh s ateroskleroticheskoi okkliuziei bedrenno-podkolenno-bertsovogo segmenta v stadii kriticheskoi ishemii.

Presented herein are remote results of surgical treatment of 101 patients with atherosclerotic occlusion of the femoral-popliteal-tibial segment in the stage of critical ischaemia. The choice of the reconstructive operation was made based on the developed criteria. Femoral-popliteal shunting into the isolated segment of the reversed great saphenous vein was performed in 48 (47.52%) patients, and 53 (52.48%) patients underwent distal femoraltibial bypass grafting according to the in situ technique. The five-year patency of the graft in these groups was identical, amounting to 54.17 and 58.49%, respectively. In order to predict the duration of bypass graft patency in the isolated segment of the popliteal artery we worked out criteria of competence of the collateral blood flow. We also defined more exactly the indications for applying a relieving arteriovenous fistula in distal femorotibial shunting. When deciding upon a method of operative treatment, preference is given to shunting into the isolated popliteal artery in sufficient collateral blood flow.