[Prolonged paravertebral analgesia in therapy of chronic pain syndrome in critical lower-limb ischaemia]. / Prolongirovannaia paravertebral'naia analgeziia v terapii khronicheskogo bolevogo sindroma pri kriticheskoi ishemii nizhnikh konechnostei.

Chronic pain syndrome in patients presenting with lower-limb critical ischaemia may have considerable significance in progression of the degree of limb ischaemia, and quality of life of patients appears to be largely determined by adequate analgesia. Currently, there is no 'gold standard' of therapy for chronic pain syndrome in critical lower-limb ischaemia, which makes it necessary to search for new effective and safe methods of analgesia. The purpose of this study was to evaluate efficacy and safety of paravertebral analgesia compared with epidural analgesia in therapy of chronic pain syndrome in critical lower-limb ischaemia. Our prospective randomized double-centre study included a total of 40 patients suffering from atherosclerotic-genesis critical lower-limb ischaemia and pronounced unilateral pain syndrome. The patients were randomized into two equal groups comprising 20 patients each. They were comparable by the main clinical and demographic parameters, as well as by the scope of the comprehensive treatment performed. In the study group, therapy of chronic pain syndrome was provided by the method of paravertebral analgesia, with the comparison group patients receiving epidural analgesia. Paravertebral analgesia was performed with the use of ultrasound navigation, in the prolonged mode by means of using microinfusion elastomeric pumps, epidural analgesia - according to the standard technique. The use of various methods of analgesia was accompanied by a decrease in chronic pain syndrome according to the visual analogue scale by 60% within the first 24 hours, and by 65% at 72 hours thereafter, with the differences being statistically insignificant. The use of prolonged paravertebral analgesia was accompanied by neither considerable haemodynamic reactions nor the development of the motor block, however requiring significant expenditure of a local anaesthetic. The conclusion was drawn that paravertebral analgesia in lower-limb critical ischaemia turned out to be a safe and efficient method of comprehensive therapy of chronic pain syndrome.

[Comparative assessment of immediate outcomes of surgical treatment of patients with coronary artery disease and lesion of the brachiocephalic arteries].

From 2000 to 2011, a total of 52 patients with combined atherosclerotic lesions of the coronary and brachiocephalic arteries were subjected to a single-stage operation. Depending on the type of operative intervention, all patients were subdivided into two groups: Group One comprising 13 patients who underwent coronary artery bypass grafting (CABG) in a combination with simultaneous stenting of the internal carotid artery, and Group Two consisting of 39 patients subjected to CABG with simultaneous carotid endarterectomy. Assessing the intraoperative parameters revealed that in Group One patients the average duration of operations was significantly lower (179.6±6.4 minutes versus 273.2±5.6 minutes in Group Two, p<0.001) and the time of assisted circulation was less than in Group Two, averaging 75.9±4.5 versus 115.2±3.8 minutes, respectively (p<0.001). The duration of pulmonary artificial ventilation in Group One patients was less than in Group Two patients (9.7±2.6 hours versus 25±4.8 hours, respectively, p< 0.01). Also the duration of staying in the critical care unit was shorter in Group One patients than in Group Two patients (21.5±3.3 versus 82.1±8.0 hours, respectively, p<0.001). The overall hospital mortality rate amounted to 12.8% (5 patients), with all deaths having occurred in Group Two. The lethal outcomes were caused by acute myocardial infarction in three cases, one patient died of progressing multiple-organ failure on the background of acute impairment of cerebral circulation and one death was caused by thrombosis of the mesenteric artery with the development of intestinal gangrene and peritonitis. In the structure of hospital complications cardiac insufficiency was prevalent (23.1% and 59.0% for Groups One and Group Two patients, respectively, p<0.05). Analysing the incidence and structure of other postoperative complications revealed no statistically significant differences between the groups. Our study demonstrated that using surgical methods of treatment of patients with haemodynamically significant stenoses of the coronary and brachiocephalic arteries makes it possible to increase the overall survival rate in patients suffering this disease and to decrease the incidence rate of ischaemic impairments of the coronary and cerebral circulation. The hybrid method of treatment on arteries of various vascular basins may be an alternative to carotid endarterectomy and CABG, especially in patients running high surgical risk.

[Hybrid operation in combined pathology].

Presented herein are the results of successful surgical treatment for a combined atherosclerotic lesion of arteries of the coronary and carotid basin in a patient with coronary artery disease.