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.

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.

[Endovascular treatment of delayed arterial bleeding after pancreatic surgery: single-center experience]. / Rezul'taty rentgenendovaskulyarnogo lecheniya pozdnego arterial'nogo krovotecheniya posle operatsii na podzheludochnoi zheleze. Opyt odnogo tsentra.

OBJECTIVE: To evaluate technical aspects and clinical results of transcatheter arterial embolization (TAE) for delayed postoperative arterial bleeding after pancreatic surgery. MATERIAL AND METHODS: There were 821 pancreatectomies between 2012 and 2020. Delayed bleeding occurred in 106 (12.9%) patients; 74 patients were included in the study. Previous pancreatic head resection was carried out in 75.7% of cases, pancreatic body resection - in 17.6% of cases, pancreatic tail resection - in 6.8% of patients. Primary endpoint was technical success of TAE, secondary endpoints - complications after TAE, as well as recurrent bleeding after embolization. RESULTS: Angiography of celiac-mesenteric arterial system was performed in 74 patients (91 procedures). The most common sources of bleeding were gastroduodenal and superior mesenteric arteries (35.7%), jejunal arteries (13.1%), common hepatic artery (11.9%). Combination of embolization agents was applied for TAE (metal coils and non-calibrated PVA particles, 48.6%). In 11 (14.9%) patients, we applied stent-grafts. Technical success rate was 100%. Recurrent bleeding occurred in 13 (17.6%) patients. In-hospital mortality was 12.2% (n=9). CONCLUSION: TAE is an effective treatment procedure in patients with arrosive bleeding. This method is characterized by high technical efficiency and low in-hospital mortality, but it does not affect recurrence of bleeding.

[Endovascular treatment of arterial bleeding after pancreatic surgery]. / Rentgenendovaskulyarnoe lechenie arterial'nogo krovotecheniya posle operatsii na podzheludochnoi zheleze.

Pancreatic surgery is complex and associated with a risk of complications including bleeding. Bleeding after pancreatic surgery is rare, but characterized by high mortality. This review is devoted to classification, diagnosis and treatment strategies for bleeding after pancreatic surgery. Methods and results of endovascular surgery are of special attention.

Myocardial revascularization in Russian Federation for acute coronary syndrome in 2016-2020.

Aim    To analyze the number of cases of acute coronary syndrome (ACS) [ST segment elevation myocardial infarction (STEMI), non-ST elevation acute coronary syndrome (nSTEACS)] and results of myocardial revascularization for ACS as a part of the monitoring performed by the Ministry of Health Care of Russia*. This analysis allows, on one hand, providing control of morbidity and mortality of patients with socially significant pathologies and, on the other hand, monitoring the effectivity of treatments to identify and correct their shortcomings. Time-related changes in results of myocardial revascularization performed for ACS patients in the Russian Federation in 2020 were analyzed and compared with the values of 2016-2019 based on data of the Russian Ministry of Health Care monitoring.Material and methods    Yearly absolute, relative, and calculated indices of revascularization for ACS were analyzed and compared based on data of the Russian Ministry of Health Care monitoring in 2016-2020.Results    In the Russian Federation in 2020, the lowest number of hospitalizations for ACS (403, 931) was recorded with an unprecedented ratio of 1 / 1.8 for STEMI/nSTEACS, respectively. In Russia in 2020, the proportion of primary percutaneous coronary interventions (pPCI) for STEMI continued growing; it reached 44% and peaked to the maximum for 2016-2020. At the same time, the thrombolytic therapy (TLT) remained essential in the structure of reperfusion strategies during those years (24.0-27.3 % of all STEMI cases). Total death rate of admitted patients with STEMI in Russia was stable at the level of 13.1-14.6 %. In 2020, there were no significant differences in quality indexes of the treatment for STEMI from the previous period (2016-2019). A yearly relative increase in the number of PCIs for STEACS (from 16 % in 2016 to 30 % in 2020 and from 30% to 46% for high-risk nSTEACS) was observed. In 2020, a significant increase in death rate was observed for nSTEACS as a whole (to 4.1 %) and for individual subgroups (high-risk nSTEACS, to 4.5 %; after PCI for nSTEACS, to 1.8 %; and after PCI for high-risk nSTEACS, to 2.8 %) whereas mean death rate values in these subgroups in 2016-2019 were 2.75 %, 3.45 %, 1.5 %, and 2.3 %, respectively.Conclusion    The analysis of revascularization indexes in ACS patients based on the Ministry of Health Care of Russia monitoring performed in 2016-2020 showed a number of positive trends, including an increase in the total number of revascularization procedures; a decrease in the time from the disease onset to the endovascular treatment; an increase in the availability of stenting for severe ACS; and general stabilization of the mortality. On the other hand, the Russian Federation is considerably behind European countries in several qualitative and quantitative parameters of health care in ACS, such as pPCI availability, symptom-to-balloon time, total mortality of all hospitalized STEMI patients, and revascularization for nSTEACS. Despite the gradual improvement of relative quantitative indexes of myocardial revascularization for ACS, negative changes in the absolute number of myocardial revascularizations for various forms of ACS and a notable increase in the death rate in nSTEACS were observed in 2020, including patients after PCI. There is no doubt that the negative results of myocardial revascularization in Russia in 2020 were due to the effect of the COVID-19 pandemic.* monitoring of measures to reduce the mortality from ischemic heart disease (letters of the Ministry of Health Care of the Russian Federation of 13.03.2015 # 17-6 /10 / 1-177 and of 24.07.2015 # 17-9 / 10 / 2-4128), which includes monthly collection of data on the Federal Research Institute for Health Organization and Informatics portal, the Automated System for Monitoring of Medical Statistics, at http://asmms.mednet.ru.

[Comparison of the results of surgical treatment and stenting for aortic coarctation and recoarctation]. / Sravnenie rezul'tatov khirurgicheskogo lecheniia i stentirovaniia pri koarktatsii i rekoarktatsii aorty.

Aortic coarctation is one the most commonly encountered congenital defects of the cardiovascular system. The natural course of the defect is unfavourable: 50 % of patients with aortic coarctation die before reaching the age of 32 years. Surgical operations aimed at correcting aortic coarctation were first introduced into clinical practice as early as in 1944, with the first use of stenting dating back to 1993. Great experience in surgical and endovascular interventions for aortic coarctation and recoarctation has since been accumulated. The article is a review of both foreign and Russian literature concerning current problems of surgical treatment and stenting for aortic coarctation and recoarctation, also containing a detailed analysis of the works aimed at comparing the immediate and remote results of surgical treatment and stenting for aortic coarctation in senior children, adolescents, and adults. It was shown that in some patients stenting for aortic coarctation and recoarctation may be considered as an alternative to conventional surgical methods of treatment.

[Results of implementation of a 'Complex of measures to improve medical care for patients with stroke in the Russian Federation']. / Rezul'taty realizatsii 'Kompleksa meropriiatii po sovershenstvovaniiu meditsinskoi pomoshchi patsientam s ostrymi narusheniiami mozgovogo krovoobrashcheniia v Rossiiskoi Federatsii'.

Vascular diseases of the brain and heart are the main cause of death and disability of the population of the Russian Federation. The social and economic burden of acute cerebral circulation disorders necessitated the development of a national program for the care of patients with acute vascular diseases. As a result of the implementation of a set of measures to improve medical care for patients with stroke over the past decade, the regions of the Russian Federation managed to create an 'insult network', equip the departments with high-tech diagnostic and therapeutic equipment, and train medical personnel. Due to the implementation of modern methods of treatment of stroke, the rates of disability and mortality from stroke have decreased.

Comparative assessment of Fontan operation in modifications of atriopulmonary and total cavopulmonary anastomoses.

OBJECTIVES: The optimal technique of the Fontan operation remains disputable. This investigation was aimed at the comparison of atriopulmonary and total cavopulmonary anastomoses. METHODS: The results of 81 operations of total cavopulmonary and 69 operations of atriopulmonary anastomosis, performed from 1983 to 1995 were analysed. A control study was carried out 1-10 (3.7 + 0.2) years after the operation in 80 patients (36 after total cavopulmonary and 44 after atriopulmonary anastomoses). 70 patients were studied several times. Cardiac catheterization was done in 70 patients. In 78 patients central hemodynamical indices were studied during exercise. RESULTS: Preoperative hemodynamical indices were not reliably different in the two groups. Early mortality after total cavopulmonary anastomosis was 15%, after atriopulmonary anastomosis 23%. The highest mortality was seen when the criteria of Choussat et al. (Choussat et al. Pediatric Cardiology. Edinburgh: 1977:559-566) were surpassed. In the early postoperative period after total cavopulmonary anastomosis circulatory insufficiency was less marked, transsudation from pleural cavities was reliably lower (15.3 + 1.2 versus 25.5 + 1.8 ml/kg/day, P < 0.01). Arrhythmias were more common after total cavopulmonary anastomosis (18.5 versus 12%). Late mortality after total cavopulmonary anastomosis was 6%, after atriopulmonary anastomosis 12%. 82% of patients after atriopulmonary anastomosis and 81% after total cavopulmonary anastomosis were in NYHA classes 1 and 2.7% of patients after total cavopulmonary anastomosis and 11% after atriopulmonary anastomosis were reoperated. Physical tolerance rose stepwise in both groups and by the third post-operative year reached 75% of normal level. At this time we saw the most optimal hemodynamical indices during exercise. However, the best hemodynamics during exercise were seen after atriopulmonary anastomosis. CONCLUSIONS: Total cavopulmonary anastomosis is accompanied by lower mortality rate and a more favourable course of early postoperative period. However, the best long-term functional results are obtained after atriopulmonary anastomosis.

Surgical reinterventions after modified Fontan operations.

BACKGROUND: Surgical reinterventions after Fontan operations are still associated with high mortality. This investigation aims to summarize our experience with such repeated operations and to assess their efficacy. METHODS: In 1983 through 1995 we performed 162 different modifications of Fontan operation. Repeated interventions were needed in 15 cases (9%). An analysis of all these cases is presented. RESULTS: Repeated operation consisted of the closure of residual interatrial communication (3 patients), atrioseptostomy (4), subaortic stenosis resection (1), pulmonary balloon valvuloplasty (1), embolization of residual right ventricular-pulmonary arterial communication (1), pericardectomy (2), pleurectomy (1), pacemaker implantation (1), and takedown of the Fontan operation (1). The results of operation were judged as good in 6 cases (40%) and as satisfactory in 5 (33%); 4 patients (27%) died. CONCLUSIONS: Repeated interventions aimed at the elimination of technical errors of the Fontan operation are successful in most cases. Atrial septostomy gives good results in the absence of anatomic causes of cardiac failure such as subaortic obstruction and atrioventricular valve insufficiency.

Right subscapular artery catheterization for balloon valvuloplasty of critical aortic stenosis in infants.

This study was performed to evaluate the utility and safety of catheterizing the right subscapular artery for balloon valvuloplasty of critical aortic stenosis in infants. Twenty-one patients, age 20 days to 17 months, underwent attempted valvuloplasty through the surgically exposed right subscapular artery. Five or 7Fr catheters with balloon diameters of 7 to 10 mm were used. Valvuloplasty was successfully performed using this approach in 11 patients. In 2 other patients, the subscapular artery would not accommodate the balloon angioplasty catheter (7Fr), and the arteriotomy was extended into the axillary artery. In these 13 patients, the peak systolic pressure gradient across the aortic valve was decreased from 85 +/- 23 to 33 +/- 7 mm Hg. Moderate aortic regurgitation developed in 3 patients. In the remaining 8 patients, valvuloplasty could not be performed through the right subscapular artery. In 2 patients, the right subclavian artery was anomalous and led to the descending aorta. In 6 small patients, no catheter could be advanced across the aortic valve. In 1 of these patients, a guidewire perforated a coronary sinus of Valsalva causing death. Overall, valvuloplasty using the right subscapular arterial approach was successful in 13 of 19 infants (68%) with normal right subclavian arteries, including all 10 such patients weighing > or = 5.5 kg. No clinically significant peripheral vascular complications or brachial plexus injuries occurred. Thus, the right subscapular arterial approach is an alternative route to be considered when planning balloon aortic valvuloplasty in infants.

Limitations of using arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions.

To explore the limitations of using arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions, we evaluated 195 patients with combined lesions undergoing CABG, either alone or in combination with peripheral vascular reconstruction between October 1987 to October 1990. Doppler flow and spectral analysis revealed that 14 patients (7.1%) had atherosclerotic lesions of the subclavian artery, in whom ipsilateral internal mammary artery pedicle graft was contraindicated for myocardial revascularization. Out of 195 patients, 165 patients were subjected for aortography, 18 of whom (10.9%), revealed atherosclerotic involvement of the celiac trunk, thereby contraindicating the use of gastroepiploic artery for myocardial revascularization. Thus in our experience use of arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions is limited.