[Reconstruction of caval veins]. / Rekonstruktsiya polykh ven.

OBJECTIVE: To study the possibilities and results of reconstruction of caval veins. MATERIAL AND METHODS: We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins. RESULTS: All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged. CONCLUSION: Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.

[Anticoagulant therapy in comprehensive treatment of acute thrombosis of lower-limb deep veins].

The authors analysed the findings of examination and treatment of 61 patients presenting with acute thrombophlebitis of lower-limb deep veins, also investigating the risk factors for the development of acute thrombophlebitis. Of these, 54 (88.5%) patients were found to have various risk factors. During treatment we studied efficacy of anticoagulant therapy, also carried out examination of the blood coagulogram. Depending on the method of anticoagulant therapy, all patients were subdivided into two groups: Group One patients (n=30) received a combination of heparin and warfarin and Group Two patients were given monotherapy with heparin alone. It was determined that combined administration of two anticoagulants resulted in prolongation of the value of the activated partial thromboplastin time by 20% from the normal one in the majority of those receiving it (n=22, 73.3%), whereas in Group Two patients it was observed only in 12 (38.7%) patients. The values of the international normalized ratio in Group One patients were within the therapeutic (2.0-3.0) range, while in Group Two patients they were less than 2.0. There were neither haemorrhagic nor thrombolytic complications associated with administration of anticoagulants in either group. A combination of two anticoagulants turned out to be more effective for reaching adequate and safe hypocoagulation. The authors also worked out a therapeutic regimen and policy of follow up of patients presenting with acute thrombophlebitis. The comprehensive set of treatment included an effective route of paransal administration of the therapeutic mixture, favourably influencing the course and regress of the inflammatory process. The immediate results were as follows: good and satisfactory outcomes amounted to 93.4%, and poor results were noted in 6.6%. The short-term results were studied for up to 6 months revealing that 83% of patients had evidence of recanalization of the thrombosed veins, and only 17% demonstrated chronic occlusion.

[Present-day possibilities of surgical management of tumour-like forms of arteriovenous angiodysplasias].

Described herein is the treatment policy pursued in a relatively uncommonly encountered variant of congenital vascular pathology, i. e. arteriovenous angiodysplasias. We operated a total of twenty patients presenting with various localization of the pathology concerned. The patients average age amounted to 18 ± 8.6 years. In order to make the diagnosis of the disease and to accomplish the tactical missions we used duplex scanning and angiography. According to the opinion of the authors, in this form of angiodysplasias using any method of treatment independently cannot be efficient. Arteriovenous angiodysplasias were treated by a combined method including endovascular embolisation or sclerotherapy of the afferent vessels and surgical removal of vascular formations. The use of such therapeutic policy makes it possible to attain positive results in 75% of patients.

[The efficacy of arterio-venous fistulas in the treatment diffuse arterial diseases].

The experience of treatment of 32 patients with diffuse peripheral arterial diseases was analyzed. All patients underwent the by-pass surgery with the formation of unloading arterio-venous fistulas. Indications to the formation of A-V fistula was the high peripheral resistance of the vascular wall. 4 variants of by-pass were used: the side-by-side by-pass n=14; the preanastomotic adjuvant arterio-venous shunt n=7; and 2 original author modification. The analysis of the results demonstrated no statistical difference between A-V shunts modifications. However, the methods, proposed by the authors has some advantages due to the higher increase of the perfusion area.

[Substantiation of surgical decision making in congenital lesions involving the inguinal major vessels n injection drug abusers].

The article is dedicated to surgical policy pursued in lesions involving femoral major vessels in the inguinal region, having developed due to long-term abuse of injection narcotic drugs. Analysed herein are the outcomes of surgical management of thirty-one patients presenting with a pulsating haematoma and inguinal pseudoaneurysms of post-injection aetiology. According to the authors' opinion, choosing the appropriate scope of the would-be operation is too complicated largely due to peculiarities of the pyo-necrotic process in this zone. Revealed and systematized characteristic of this category of risk factors that pose a real threat of severe consequences when any type of surgery. The authors recommend using only 2 categories of operations: ligation of damaged vessels in the groin area as an independent operation and ligation of vessels with the restoration of blood flow through lateral bypass autovein. Indications for their use, particularity of performing the ligated operations in the inguinal region was given.

[Methods of operative interventions in postthrombotic disease of the crus].

Analysed herein are the findings of examination and outcomes of surgical management of 43 patients presenting with crural postthrombotic disease. Of these, eighteen patients were diagnosed as having stage II chronic venous insufficiency (CVI) and the remaining 25 had stage III CVI. All the patients had previously experienced acute thrombosis of deep crural veins. Eight patients had developed thrombosis during or in the immediate terms after typhoid fever, seven women in the postpartum period, and a further four women after endured operations on the organs of the abdominal cavity or small pelvis. Twelve patients had developed thrombosis after a blunt injury of the limb. In a further 12 cases, the causes of thrombosis coujinot be revealed or traced properly, thus having remained unknown. The disease duration varied form twelve months to nine years. Venous haemodynamics was studied by means of duplex scanning and phlebography, with the latter used if indicated. The prevailing role in making appropriate diagnosis was found to belong duplex scanning. Thirty-one patients were subjected to combined surgical procedures. Twelve subjects underwent single-stage operations. The main stage of the intervention in combined surgery consisted in resection of the anterior tibial vein and dissection of communicating veins of the medial surface of the crus according to the Savelyev-Konstantinova's technique; phlebectomy was performed on the crus only. The remote period was marked by a decrease in the CVI's severity, i.e., transition to a lesser-severity degree in eighteen patients (41.9 %), while in twenty-five cases (58.1 %) CVI remained at the baseline level. Totally, positive results were obtained in forty patients (93.0%). Three patients (7.0 %) initially presenting with grade C5-6 CVI and subjected to single-component operations were found to have poor outcomes. Surgical correction of the venous blood fl ow does by no means cure the patient but appears to result in persistent remission of the disease, with adequate rehabilitation after surgery leading to considerable regression of CVI.

[Surgical treatment of cervical rib syndrome].

The authors report herein the results of examination and surgical management of fifty-one patients presenting with cervical ribs. Of these, there were 33 women. Compression of the neurovascular bundle (NVB) was found to be caused by a supplementary cervical rib in twenty-three patients while in the remaining 28 patients by a rudimentary cervical rib. Twenty-two patients were found to have clinical manifestations of Raynaud's syndrome. The presence of abnormal cervical ribs was determined roentgenologically. All the patients with rudimentary cervical ribs and twelve of the 23 patients with supplementary cervical ribs were diagnosed as having bilateral abnormalities. Haemodynamics was studied by Doppler ultrasonography revealing blood flow impairments in upper-limb arteries in Edson's test in patients with supplementary cervical ribs and Raynaud's syndrome. In rudimentary cervical rib - only in the development of Raynaud's syndrome. The nervous function was studied by means of electroneuromyography (ENMG). All the patients were diagnosed as having a significant decrease in both motor and sensitive nervous conductivity of the radial and median nerves. All patients were operated on under endotracheal anaesthesia. Decompression operations were carried out in fifty-one patients, with selective thoracocervical sympathectomy performed in twelve. For treating rudimentary cervical rib, we worked out a combined method of an operative intervention. Analysing the obtained surgical outcomes showed the following: forty-four patients (86.3%) endured the operation with no complications. Intraoperative complications were noted to occur in 5.9% of patients and complications in the immediate postoperative period were observed to develop in 7.8% of patients. All the encountered complications turned out transient, easily amendable to treatment, and did not influence the final outcome of the operation. In the remote period up to 5 years positive results remained in 90.2% of the patients.

[Falconer-Weddel's costoclavicular syndrome].

Analysed herein are the findings of examination and outcomes of surgical management of fifty-eight patients (25 men and 33 women) presenting with Falconer-Weddel's costoclavicular syndrome in which the subclavian artery and vein and the brachial plexus at the thoracic outlet appear to be compressed. Of the 58 patients,five subjects were found to have a rudimentary cervical rib and three more (5.3%) patients had trophic disorders on their digits fingers: dystrophy of the nail plates, their fragility, periodically opening trophic ulcers at the digital tips and one patient presented with gangrene of the inguinal phalanx of the middle finger. Three patients had hyperemia of the face. A further four patients had roughening, hyperkeratosis of the skin of the hands, cracks. The presence of the supernumerary ribs was determined roentgenologically. Haemodynamics was studied using Doppler ultrasonography making it possible to reveal disordered blood flow in the upper-limb arteries in the physiological position assumed, in the Adson test as well as with Raynaud syndrome, which was observed in 39 patients. The function of the nerves was studied using electroneuromyography (ENMG). All patients were operated on under endotracheal anaesthesia. Decompression-medical operations were carried outperformed in all 58 patients, with the following four types of interventions being performed: transaxillary resection of the first rib combined with sympathectomy carried out in 23 patients, resection of the first rib without sympathectomy in eighteen patients, resection of the first rib via a surpraclavicular approach in four patients, scalenotomy and selective cervicothoracic sympathectomy in 13 patients.

[Successful surgical repair of aortic arch torsion and aneurysm].

Described herein is a rarely encountered in clinical practice case regarding surgical management of pathological tortuosity of the aortic arch with a simultaneously present aneurysm thereof. The defect was surgically corrected in the setting of extracorporeal circulation. The tortuous and aneurysmatic aortic arch was resected within the boundaries of the healthy tissues, duly followed by establishing an end-to-end anastomosis between the edges of the resected aorta.

[Reconstructive operations in unilateral occlusions of the iliac vein].

Analysed herein are the findings of the examination and outcomes of surgical management of 48 patients with unilateral occlusion of the iliac veins. Of these, grade I chronic venous insufficiency (CVI) was observed in 12 patients and grade II SVI in 28 subjects. Grade III CVI's with trophic ulcers were diagnosed in 8 patients. In a further eight patients, the primary cause of thrombosis had been catheterization of the femoral vein in childhood. Nine patients developed thrombophlebitis following the endured enteric fever, with four patients having developed it after an injury, four - after an operation on the abdominal cavity organs, and four - after delivery. In the rest 19 patients, we failed to reveal the cause of thrombophlebitis. The venous haemodynamics was studied by means of the following methods: Doppler ultrasonography, duplex scanning and phlebography. The latter was used by the indications, with the duplex scanning technique having proved to play the leading role. The patients with postthrombotic lesions of several segments appeared to have a severer degree of CVI. The venous circulation was more compensated in the well-developed suprapubic collateral network. The patients were subjected to two types of surgical interventions: the Palm-Esperon operation with and without the establishment of the AV fistula (26), and correction of the suprapubic collaterals (21). The indication for establishing the AV fistula was the difference of pressure in the femoral veins of not less than 50 mm Hg. The correction of the suprapubic collaterals was carried out in considerably varicose-dilated saphenous veins of the suprapubic area. Disseminated lesions of the deep veins and secondary alterations in the tibial veins were additionally managed and coped with by the appropriate correcting operations performed on the crus. Postoperative complications were observed in two (4.2%) patients: thrombosis of the femoral-iliac shunt and of the corrected suprapubic vein. Favourable outcomes were obtained in 46 (95.8%) patients.

[Successful surgical treatment of veritable internal carotid aneurysm due king-king].

In the report authors had shown the clinical observation (case) of surgical treatment of the patient with veritable lateral aneurysm of right internal carotid artery appeared due of its king-king.

Revascularization in distal lesions of upper extremity arteries.

A study was made of the course of ischemia and hemodynamic disorders in 53 patients with occlusion of the distal arterial system of the upper extremities. Circulation was examined by ultrasound Doppler, tetrapolar rheology, transcutaneous oxymetry and angiography. Critical ischemia was discovered in 58.5% of patients. In occlusion of one of the forearm arteries, extremity circulation was made for. Circulatory decompensation was recorded in occlusion of both forearm arteries with intact distal bed and non-functioning palmar arches of the hand as well as in lesions of hand and finger arteries. All 53 patients were operated on, 66 operations were accomplished using magnifying optic appliances. Provided the distal bed was well preserved, use was made of direct revascularization techniques (36) whereas non-standard methods were employed in the event of its obliteration: arterialization of the outlets of the subcutaneous veins of the hand and autotransplantation of the greater omentum (30). Beneficial results were obtained in 91.5% and unsatisfactory in 8.5% of patients. The lethality accounted for 1.2% while the incidence of amputations was quoted as 5.7%. Good results offer the period as long as 5 years were well preserved in 87.6% of patients. Our experience indicates the efficacy of the use of revascularization techniques for the treatment of different versions of occlusion of the distal segments of upper extremity arteries.

[Surgical management of thromboses and aneurysms of the reconstructed vessels].

This paper analyses the results of reoperations in 52 patients with thromboses (n=42) and aneurysms (n=10) of the reconstructed vessels. The main causes of their development were progression of vascular disease and suppuration of a surgical wound. No relationship was established between complications and the type of suture materials. The diagnosis of the disease was made on the basis of the clinical data and duplex scanning. The operation of choice for thromboses of aortofemoral grafts was retrograde thrombectomy with reconstruction of the distal anastomosis, which was performed in 24 patients. Despite the controversial data on the possibility of thrombectomy from vein grafts the authors could accomplish it in 6 of 10 patients with thromboses of the femoro-popliteal vein bypasses. It is emphasized that the basic component of reoperations for occlusions of the femoro-popliteal segment lies in the formation of a tension-release arterio-venous fistula. In the postoperative period, rethrombosis of the reconstructed vessels occurred in 2 patients, arrosive bleeding in 3; limb amputation was performed in 3 patients, one of whom died from peritonitis.

Traumatic injuries of the popliteal and tibial arteries: limb ischemia and problems of surgical management.

This paper analyzes the results of examination of 106 patients with traumatic injuries of the popliteal (n=36) and leg arteries (n=70) including gunshot (n=48), punctured and incized (n=32), contused-crushed (n=17) wounds and blunt (n=9) traumas. Sixty-two patients were admitted within 8 hours of injury and 20 within 8 to 24 hours, 24 patients within 1 to 15 days. Sixty-five patients had been rendered first aid at other medical institutions. It is to be noted that the prehospital diagnostic and tactic errors had been made in 67.7% of cases. In the patient group with injuries of the leg arteries, the severity of ischemia correlated with the number of the injured arteries and in the group of patients with popliteal artery injuries, there was a relationship between the severity of ischemia and the character of injury. In injury of the popliteal and leg arteries, severe limb ischemia was present in 72.2 and 34.3% of cases respectively. The surgical management was worked out depending on the severity of the patient general condition and the degree of limb ischemia. Primary limb amputation was performed in 17 (16%) patients; the indications for it were moist gangrene, severe traumas with major destructions and defects of other anatomic structures (inadvisability of revascularization), critical condition of the casualty, severe circulatory decompensation observed even in the early times of referral, when it was necessary to save the patient's life. Different surgical interventions were undertaken in 89 patients: ligation of the vessel in the event of one artery injury (24), revascularization (61) and fasciotomy, hematoma evacuation and bone reposition (4). Eleven (10.4%) patients underwent secondary amputation. Beneficial results with complete circulatory compensation were obtained in 78 (73.6%) patients. The total incidence of amputation and lethality accounted for 26.4%.

[Surgeries on major vessels in removal of different tumors]. / Operatsii na magistral'nykh sosudakh pri udalenii opukholei razlichnoi lokalizatsii.

Experience in diagnosis and surgical treatment of 49 patients with tumors of different localization close to their major with main vessels is analyzed. Two variants of tumor - vessel interrelation were seen, patients with iatrogenic vascular lesions were included into a separate group. In 9 patients (group 1) only extravasal compression by the tumor was seen. Most of these tumors were benign. In 15 patients (group 2) reconstructive vascular surgeries were performed because of close interrelation with the tumor or tumor spread into the vessel. Most of these tumors were malignant. Iatrogenic lesions of arteries during surgeries were in 25 patients (group 3). It is demonstrated that duplex sonography permits to diagnose affection of vessels by tumors without invasive procedures. All the patients underwent vascular reconstruction simultaneously with tumor removing. Sceletization of vessels with their decompression was the surgery of choice in benign tumors. In malignant tumors it is recommended to remove the tumor with affected segment of vessel and repair of blood flow. Ligation of vessel may be justified in some cases.

[The place of vascular surgery in the treatment of cancer patients]. / Mesto sosudistoi khirurgii v lechenii onkologicheskikh bol'nykh.

The aim of the present work was to analyze the reported data related to the diagnostic potential of delineating the degree of blood vessel involvement into the tumorous process in patients with cancer diseases of varying sites and to the choice of the method for surgical treatment of this group patients. Half century ago an idea was advanced of the necessity of performing vascular operations during evacuation of tumors of certain sites. Based on the analysis of numerous publications the authors have established that the lowering of the lethality and improvement of the quality of life in patients with oncopathology are determined in many respects by one-stage operations performed on the great vessels, allowing to broaden the indications for tumor resection. The review elucidates the current achievements of vascular surgery linked with oncology, mirrors the historical viewpoint of the given problem, describes an experience of different authors gained with the use of the modern noninvasive research modalities in the diagnosis of vascular involvement into tumorous growth. As dependent on the site, tumor morphology and hemodynamic significance of the affected vascular segment, the indications have been worked out for different types of operations on the arteries and veins. The authors emphasize the potential and safety of great vessel ligation after radical resection of tumors of certain sites.

Surgical strategy for combined wounds of vessels and internal organs.

Surgical strategy and outcomes were analysed for 51 patients with combined wounds of internal organs and major blood vessels, with total 87 organ and 65 vessel injures. In 29 cases intracavity vessels were injured, in 22 - peripheral ones. In 47 cases (92.1%) traumas were gunshot. On admission 43 patients were in poor clinical condition with III-IV grade shock. The delay of surgical intervention did not exceed 30-40 min, all patients were operated in emergency, regardless of complete preoperative preparation. Blood reinfusion was used for all intracavity bleedings. The consequence of surgical steps was determined by localization of vascular trauma, bleeding intensity and severity of organ injuries. In order to decrease invasiveness and duration of surgery, conventional wound suturing was used for 53 organs, vascular plasty and sutures - in 35 cases, ligation of vessels - in 27. Lobectomy was executed in 1 case, intestinal resection and anastomosis - in 8, ileo-and colostomy - in 7 patients. Total 73 internal organs and 62 vessels were reconstructed. Postoperative complications have developed in 30 patients (58.8%), lethal outcome occurred in 3 patients during operation and in 10 (25.4%) - postoperatively. The majority of complications and deaths were observed for thoracoabdominal traumas. High postoperative mortality was also seen for patients with combined injuries of abdominal organs and vessels (13.7%).

[Surgical strategy in traumatic lesions of the popliteal artery]. / Khirurgicheskaia taktika pri travmaticheskikh povrezhdeniiakh podkolennoi arterii.

An examination and treatment of 32 patients with injured popliteal arteries are analyzed. Among the etiological factors there were gunshot wounds (16), crushed (4), punctured-incised (7) and blunt (7) traumas. Combined injuries of the popliteal vein were diagnosed in 12 patients, and injuries of the bones--in 16 patients. Errors were made in 19 cases at the prehospital stage: late diagnosis of the injury (11), transporting the patient in the state of shock (5), ligation of the popliteal artery (3). The term of extremity ischemia more than 8 hours was noted in 13 admitted patients. Decompensation of circulation was diagnosed in 22 patients. The primary amputation was performed on 6 patients with moist gangrene. Vascular reconstructions were made in 26 cases including the autovenous prosthesis and circular suture. Secondary amputations were fulfilled to 6 patients. Three patients died. Good results were obtained in 20 cases.

Surgical management of traumatic injuries to the tibial arteries.

Altogether 60 patients with traumatic injuries to the tibial arteries were entered into the study. Twenty-four patients presented with gunshot, 24 with stab and incised, 10 with contused and lacerated wounds, and 2 patients had blunt traumas. Thirty-nine patients were admitted to the clinic within the period as long as 8 hours since the time of wounding, 9 patients within 8 to 24 hours, and 12 patients within the period as long as one to 15 days. 39 patients had been rendered first medical aid at other treatment institutions. It was established that prehospital diagnostic, tactic and technical errors had been made in 25 of the 39 patients. All the patients were distributed into three groups: group I (n=8) included patients with isolated injuries of one of the tibial arteries; group II (n=11) with injuries of two arteries and group III included patients with damage to all three arteries. In group I, circulation remained made for irrespective of the times of ischemic state existence. In groups II and III, all the patients demonstrated circulatory decompensation. Surgical management depended on the severity of the general condition and the degree of limb ischemia. Primary amputation was indicated to 11 (18.3%) patients (humid gangrene was diagnosed in 5 patients, severe trauma with major defects of soft tissues and bone fractures in 6 patients). The remaining 49 victims underwent different surgical interventions such as ligation of the vessel at injury to one artery (23); revascularization (22); fasciotomy, hematoma evacuation and reposition of the bones in an isolated form (4). Five (10.2%) patients required secondary amputation. Beneficial results with complete circulatory compensation were obtained in 44 (73,3%) patients. The overall amputation rate accounted for 26.6%.

[Blood flow measurement in palmar arterial arch of hand and digital arteries]. / Opredelenie krovotoka v ladonnoi arterial'noi duge i arteriiakh pal'tsev kisti.

As a result of examination of 20 healthy people by the method of ultrasound dopplerography normal values of blood flow in palmar arterial arch of the hand and digital arteries were established. In the course of examination by this method of 50 patients with various diseases of arteries of upper extremities hemodynamically responsible areas for lowering of blood flow were revealed. These were axileary artery, bifurcation of the brachial artery, both arteries of the forearm and arterial arch of the hand. Blood flow intensity in the arteries of the hand and fingers refleds the condition of collateral blood flow in the upper extremity.