Improving transcatheter bioprostheses and systems of their delivery, gaining surgical experience, as well as optimizing patient selection made it possible to achieve high levels of efficacy and safety of the procedure of transcatheter implantation of the aortic valve (AV). Nevertheless, complications of this technique with a negative influence on both short- and long-term outcomes are still encountered in many patients. Despite the fact that transcatheter implantation of the AV has historically been associated with lower incidence of hemorrhagic events than traditional surgery, bleeding occurring during this operation is fraught with a worse prognosis. Complications of the vascular access still remain the main cause of hemorrhage. To assess the incidence, predictors and prognostic significance of major vascular complications associated with the transfemoral vascular access for transcatheter implantation of the aortic valve. This retrospective study initially enrolled a total of 628 patients who underwent transcatheter implantation of the AV from March 2015 to October 2024. After exclusion of patients with other than transfemoral vascular approach, as well as with unsatisfactory quality of preoperative multislice computed tomography not allowing for the assessment of vascular anatomy, the final analysis included 548 patients. The primary endpoint of the study was defined as predictors of major vascular complications of the transfemoral approach after transcatheter implantation of the AV, with the secondary endpoint being long-term survival and freedom from cardiovascular death in patients having endured nonfatal major vascular complications of the access site at the in-hospital stage after transcatheter implantation of the AV. There were a total of 32 major vascular complications. Of these, 3 (0.6%) resulted in a lethal outcome, with 29 (5.3%) accompanied by BARC type 3a and 3b bleeding. Puncture percutaneous vascular access was used in 94.9% of patients. The most frequently applied method of vascular access closure was a combination of two ProGlide devices (70.9%). The group of patients with major vascular complications of the transfemoral access was found to have a higher frequency of puncture of the left common femoral artery (21.9% vs 10.5%, p=0.04), as well as a longer length of hospital stay (13.3±8.3 vs 9.4±5.8, p=001). The only independent predictor of major vascular complications was the left side of the vascular access (odds ratio 8.85; 95% confidence interval 1.58-69.40, p=0.02). With an average follow-up period of 2.1±2.2 years, the log-rank test revealed no statistically significant differences in freedom from all-cause mortality (log-rank p=0.11) and freedom from cardiovascular death (log-rank p=0.30) in patients with and without non-fatal major vascular complications of the access site after implantation of the AV. The incidence of major vascular complications of the access site after the procedure of transcatheter implantation of the aortic valve amounted to 5.9%. The only independent predictor of major vascular complications was the left side of the vascular access. The development of major nonfatal vascular complications at the in-hospital stage influenced neither survival nor freedom from cardiovascular death in the remote period.
The purpose of the study was to compare safety and efficacy of endovascular treatment (EVT) and hybrid repair (HR) using 'Supera' stents in patients with combined lesions of the iliac arteries and common femoral artery. This pilot randomized study was registered on ClinicalTrials.gov (identifier: NCT03315884). The patients in the EVT group after recanalization and balloon angioplasty of the iliac arteries and common femoral artery underwent throughout stenting. The HR-group patients were subjected to recanalization and stenting of the iliac arteries in combination with endarterectomy from the common femoral artery and angioplasty with a xenopericardial patch. We compared short-term (30-day) and one-year results, including complications and patency rates. A total of 62 patients were randomized into two equal groups (31 EVT and 31 HR). The average length of the hospital stay in the EVT-group patients amounted to 3.9±1.2 days vs 7.9±2.7 days in the HR group, p=0.001. 30-day complication rates were 9.7% and 22.6% in the EVT and HR groups, respectively, p=0.17. Primary patency was 81% in the EVT group and 94% in the HR group, p=0.12. There were no statistically significant differences in secondary and primary assisted patency during 12 months, with no myocardial infarction, lethal outcomes, nor amputation. The findings of this pilot randomized trial demonstrated safety and one-year efficacy of EVT in patients with tandem lesions of the iliac and common femoral arteries. The EVT-group patients showed a shorter length of hospital stay, a tendency toward a decrease in perioperative complications, and comparable to HR parameters of primary patency within 12 months.
Surgery of arterial aneurysms in the Russian Empire began in St. Petersburg in the 1806--1810s at the Medical and Surgical Academy under the leadership of I.F. Bush (Glossev S.P., Kryukov Yu.Yu., 2022). The further development of this area of surgery until the middle of the XIX century was described by Yu.Yu. Kryukov (2023) according to monographs and dissertations of that time. However, we believe that the periodical medical press, in particular, the medical newspaper 'Friend of Health', which was published from 1833 to 1869, played an important role in spreading knowledge about achievements in this field of surgery. However, there are very few studies on the history of the development of vascular surgery in this period based on the materials of the periodical press, and according to the newspaper 'Friend of Health' there is not at all. The purpose - to recreate and analyze the development of arterial aneurysm surgery in Russia in the XIX century. based on publications in the medical newspaper 'Friend of Health'. From 1833 to 1869, the medical newspaper 'Friend of Health' published 197 articles by foreign authors and 15 reports by Russian surgeons concerning surgery of arterial aneurysm. the analysis of publications on aneurysms was carried out using historical, evolutionary-chronological and comparative methods. A content analysis of the following publications was carried out: N.S. Alexandrovsky (1855) 'On hypertrophy of the right ventricle of the heart (Apeigisma activum Corvisar)'; I.V. Buyalsky 'On ligation of the unnamed artery (Ligatura arteriae innominatae)' (1833), 'On the first successful operations for ligation of popliteal aneurysms, conducted in St. Petersburg' (1850), 'On ligation of the unnamed artery' (1854) and 'Popliteal aneurysm, ruptured (Anevrisma poplitaeum ruptum), cured by ligation of the femoral artery' (1864); I.F. Geifelder 'On the case of an aneurysm of the mandibular artery' (1856); H.J. Hubbenet 'On the operation of a false aneurysm in the ulnar fold' (1855); K.I. Groom 'On three ligations of unnamed arteries made in Russia in 1827 and 1833' (1834); 'On the ligation of the artery in anevrysma arteriae Abrachialis spurium' (1836) and 'On the speech of P.A. Naranovich with an anatomical analysis of the aneurysm of the superior ascending artery that burst into the right ventricle of the heart' (1842); V. Donetskiy 'Popliteal aneurysm (Anevrisma poplitaeum), cured by injection)' (1843), K.I. Groom 'Review of the work of Dr. I.F. Hildebrand 'On the recognition and treatment of aneurysms and on the operation of ligation of arteries' (1843); N.I. Pirogov 'On the possibility of ligature on the abdominal aorta' (1839) and 'On ligation of the left common iliac artery due to traumatic aneurysm arteriae gluteae' (1852); I.V. Rklitsky 'On ligation of the external iliac artery in the case of femoral artery aneurysm' (1852). Arterial aneurysm in Russia in the nineteenth century was diagnosed quite successfully, but operations with this vascular lesion were isolated. Only 15 (2%) out of 197 reports were devoted to the description of clinical observations and surgical treatment of this disease in the newspaper 'Friend of Health', which may indicate both the difficulties of diagnosis and the high risk of aneurysm surgery. During these years, for the first time in Russia, an aneurysm of the unnamed artery was described (I.V. Buyalsky, 1833, 1834) and an aneurysm of the ascending aorta (K.I. Groom, 1842), a method of ligation of the abdominal aorta in an aneurysm of the iliac artery in an experiment (N.I. Pirogov, 1839). Operations for aneurysms performed after the discovery of anesthesia (1847) and before the introduction of antiseptics (1867) included ligation of arteries according to the methods of Antill, Filagrius, P. Brazdor, J. Gunther.
To assess efficacy of a method of modified open reconstruction of femoral and crural arteries in the absence of an autovein suitable for revascularization. The study included a total of 78 patients subjected to open arterial reconstruction. The duration of the postoperative follow-up amounted to 36 months and more. The patients were divided into 3 groups: Group 1 comprised 18 patients who underwent amodified operation including popliteal distal bypass grafting with an autovein and retrograde (or antegrade) semiclosed loop endarterectomy from the superficial femoral artery; Group 2 was composed of 29 patients subjected to classical femoropopliteal bypass grafting with a reversed great saphenous vein below the knee-joint fissure; and Group 3 consisted of 31 patients who endured X-ray endovascular reconstruction including balloon angioplasty with possible stenting of the superficial femoral artery and popliteal artery. Primary patency of the arterial bed at 1, 2 and 3 years of follow-up in Group 1 amounted to 80.9% (out of 21 patients), 75% (out of 20 patients) and 72.2% (out of 18 patients), respectively. Secondary patency after 3 years was 100%. The limb salvage rates at 1, 2 and 3 years of follow-up in Group 1 amounted to 90.4% (out of 21 patients), 85% (of 20 patients) and 88.8% (out of 18 patients), respectively. Primary patency at 1, 2 and 3 years of follow-up in Group 2 was 81.3% (out of 33 patients), 76.6% (out of 33 patients) and 68.9% (out of 29 patients), respectively. Secondary patency after 3 years amounted to 80%. The limb salvage rates at 1, 2 and 3 years of follow-up in Group 2 were 87.87% (out of 33 patients), 86.6% (out of 30 patients) and 86.2% (out of 18 patients), respectively. Primary patency of the arterial bed at 1, 2 and 3 years of follow-up in Group 3 amounted to 83.7% (out of 37 patients), 64.7% (out of 34 patients) and 48.3% (out of 31 patients), respectively. Secondary patency after 3 years was 90%. The limb salvage rates at 1, 2 and 3 years of follow-up in Group 3 amounted to 89.1% (out of 37 patients), 85.2% (out of 34patients) and 83.87% (out of 31 patients), respectively. Performing modified open arterial reconstruction by means of the proposed method makes it possible to restore blood flow in the ischemized extremity with a long occlusive lesion of femoral and crural arteries. The remote results (36 months) are suggestive of efficacy of the developed technique.
The aim of the FORAT clinical trial is to evaluate the efficacy and safety of intra-arterial intrathrombus administration of recombinant non-immunogenic staphylokinase in patients with acute limb ischemia vs surgery. Non-immunogenic staphylokinase has high thrombolytic activity and fibrin selectivity. The FORAT clinical trial is a randomized, open-label, multicenter, comparative study in two parallel groups. At the clinical sites, eligible patients (with a recruitment target of 170 subjects, taking into account a possible 10% dropout) diagnosed as having grade I-IIb acute limb ischemia will be equally randomized by the 'envelope' method into two groups assigned to receive either non-immunogenic staphylokinase or undergo surgical intervention. Surgical methods of treatment are taken to mean the possibility of endovascular intervention, open surgery and/or bypass surgery in accordance with the current National Guidelines, depending on the accepted tactics of patient management in the clinical center and the patient's condition. The study protocol presents the inclusion and exclusion criteria, sample size estimation, and the plan of the trial. The primary efficacy endpoint is the number of patients without amputations at day 30. Safety criteria will be defined as cases of hemorrhagic stroke, bleeding according to the BARC criteria (types 3 and 5), the incidence of adverse events and lethal outcomes within 30 days of follow-up. Based on the results of the study, data will be obtained on the efficacy and safety of intra-arterial thrombolysis administration of non-immunogenic staphylokinase in patients with acute limb versus surgical methods of treatment. A report will be drawn up with attachments of individual data and statistical analysis of the results. The findings of the study will be published and presented at conferences. The FORAT trial protocol was approved by the Ministry of Health of Russia No. 184 dated March 18, 2022, the Ethics Council of the Ministry of Health of Russia No. 303 dated March 1, 2022, and registered at clinicaltrials.gov No. NCT05372718 (FORAT).
Arteriovenous malformations (AVMs) are the most aggressive type of vascular malformations. They are characterized by a progressive and relapsing course, as well as by a high number of clinically significant complications. Over the past two decades, endovascular treatment of AVMs has advanced rapidly, thanks to improvements in angiographic classification, treatment approaches, and embolization materials and tools. However, due to the rarity of the condition, large-scale studies reporting clinical outcomes of embolization for AVMs remain limited. Besides, the contemporary literature lacks uniformity in defining the outcomes that should be analyzed to evaluate treatment efficacy. For this reason, results from various clinical trials cannot be consolidated, complicating the development of evidence-based recommendations. To analyze literature data and review recent studies describing treatment outcomes of peripheral AVMs. This study analyzed over 170 full-text English- and Russian-language publications from the past 10 years, sourced from PubMed, Google Scholar (English-language databases), eLibrary and the Russian Science Citation Index (RSCI, Russian-language databases). The publications cover various aspects of the management, diagnosis, and treatment of patients with peripheral AVMs. The currently available data on the definition, prevalence, and treatment of AVMs were systematized and presented herein. A structured table summarizing the findings of recent studies on endovascular treatment of peripheral AVMs is provided. This is followed by discussing the key trends and challenges in the research and management of this pathology. Most of recent domestic and foreign publications on endovascular treatment of peripheral AVMs are case reports or case series. The high recurrence rates and need for multi-stage treatment underscore the importance of advancing embolization methods and technologies. International literature increasingly includes studies with larger patient cohorts, though most remain retrospective and single-center. Research focuses on outcomes of using various embolic agents and combining endovascular with surgical approaches. The universal use of transarterial, transvenous and percutaneous embolization methods or their combinations has proven its usefulness and effectiveness. Advanced surgical experience, technical tools and a wider range of embolic agents now allow previously impossible interventions to be performed, improving quality of life or achieving complete cure even in extensive, severe cases.
To compare endovascular treatment (kissing stenting, KS) with traditional open aortobifemoral bypass grafting (ABBG) in management of patients with lesions of the abdominal aorta bifurcation and iliac arteries. We performed a single-center analysis of patients subjected to endovascular treatment with bare-metal stents by means of kissing stenting or ABBG for TASCII C/D lesions of the aortoiliac segment (AIS) from 2012 to 2021. We assessed the parameters of the perioperative risk scale (American Society of Anesthesiologists, ASA and Society for Vascular Surgery, SVS), frequency of hospital complications, early 30-day mortality and long-tern patency. The obtained results were analyzed by means of the Kaplan-Meyer curves, with the Cox regression used to determine predictors influencing patency parameters. The study included 57 patients with KS and 86 patients with ABBG. The KS group had a higher perioperative risk: ASA (ACP=0.06), SVS (ACP=0.08) and less frequent lesions of the AIS (TASC D lesions 26.3% vs 46.5%, ACP=0.202). After propensity score matching, the study comprised a total of 80 patients (40 with KS and 40 with ABBG), thus forming well balanced groups in terms of demographic data, risk factors, lower limb ischemia degree, perioperative risk: ASA (ACP=0.006), SVS (ACP=0.003) and AIS lesion anatomy (TASC D - 40%, ACP=0.000). 36-month mortality amounted to 5% after KS vs 2.5% in the ABBG group. The length of hospital stay in the KS group was significantly shorter than in the ABBG group (3.9±1.6 days vs 9.1±1.9 days, p<0.001), as well as that of ICU stay (0 days vs 2.1±0.4 days, p=0.001). The rate of early postoperative complications was comparable (7.5% vs 15%, p=0.47). Three-year primary patency was similar between the KS and ABBG groups (87.5% vs 95%, p=0.24); multivariate analysis showed that critical limb ischemia and hemodynamically significant lesions of the efferent arteries were risk factors for developing restenosis/reocclusion (6.65 [1.29; 34.37], p=0.02 and 6.4 [0.72; 50.22], p=0.04, respectively). Endovascular treatment of lesions of the aortic bifurcation and iliac arteries with bare-metal stents demonstrated primary patency comparable with that of ABBG over the 3-year follow-up period. The incidence of early postoperative complications was comparable. Thus, endovascular reconstruction of the aortoiliac segment for TASC C, D lesions by means of kissing stenting can be considered as an alternative to ABBG.
The authors herein share their experience with surgical treatment of arteriovenous fistulas (AVF), describing standard diagnostic measures and possible methods of management of this pathology, as well as analyzing the known methods of treatment of post-traumatic AVFs in a specialized vascular hospital. To determine the most effective method of surgical treatment of patients with posttraumatic AVFs in the early period of wound disease. From 2021 to 2023, a total of 58 patients with posttraumatic AVFs of the extremities were treated in the vascular centers of the National Medical Research Center of Surgery named after A.V. Vishnevsky and National Medical Research Center of High Medical Technologies - Central Military Clinical Hospital named after A.A. Vishnevsky'. Of these, 51 (88%) patients were diagnosed as having lower-limb vascular pathology and 7 (12%) had upper-limb pathology. 29 (50%) patients underwent X-ray endovascular methods of treatment, 26 (44.8%) patients were subjected to open surgical intervention, and 3 (5.2%) victims were found to have spontaneous closure of the AVF. Endovascular methods of treatment included: implantation of stent grafts in 20 (34.5%) patients, embolization with microcoils in 7 (12%) cases, and 'multilayer' stenting of the AVF zone in 2 (3.4%). Open surgical methods of treatment were as follows: arterial prosthetic repair in 20 (34.5%) patients, ligation of the arteriovenous fistula itself in 3 (5.1%) patients, autovenous plastic surgery of the arterial defect in 1 (1.7%) case, fistula disconnection with single-suture closure of the venous wall in 1 (1.7%), and resection of the damaged segment of the popliteal artery with an end-to-end anastomosis in 1 (1.7%). During the postoperative follow-up period, 3 complications developed in each study group. After endovascular treatment, these were 'local' complications in the form of thrombosis and implant dislocation in 2 patients and a recurrence of the functioning AVF in 1 case. After open surgery: wound suppuration in 1 patient, arrosive bleeding in 1 patient (with the resulting limb amputation), and a relapse of the AVF in 1 case. Each case of posttraumatic arteriovenous fistula has an individual approach to treatment. Surgical decision-making depends on such factors as the duration of AVF, diameter, localization, level of arterialization of venous blood flow, severity of changes in the walls of the affected arteries and veins. All posttraumatic arteriovenous fistulas should be treated surgically in a specialized vascular center with all modern technologies.
The problem of atherosclerotic lesions of lower limb arteries and chronic critical ischemia is currently important, requiring the development and implementation into clinical practice of modern, safe and accurate methods of examination, thus making it possible to more precisely plan and evaluate the outcomes of the operations performed. This study sought to determine the possibility of using the technique of ultrasound examination (duplex scanning) of the pedal arteries, measuring dopplerographic parameters of quantitative assessment of blood flow in the angiosomes of the foot in patients with chronic critical lower limb ischemia, depending on severity, and alterations therein following revascularization. We examined 31 patients with atherosclerotic occlusive lesions of lower extremity arteries. Of these, 3 patients had III stage chronic limb ischemia according to the Fontaine-Pokrovsky classification and 28 had IV stage ischemia. Twelve patients were diagnosed as having type 2 diabetes mellitus. The patients' age ranged from 56 to 93 years, with a male-to-female ratio of 26:5. The main dopplerographic parameters assessed were as follows: pulse waveform, ante- or retrograde blood flow in the artery examined, peak systolic blood flow velocity, maximal systolic acceleration, and acceleration time. We consider that the main advantage of using duplex scanning of the pedal arteries with measuring the maximal blood-flow acceleration is a possibility to assess namely the severity of foot ischemia. A strong inverse correlation was found between the maximum acceleration measured in pedal arteries and the severity of lower limb ischemia, as assessed according to the modified Rutherford scoring scheme (R2=0.78). It was shown that the proposed method of diagnosis is accurate and non-invasive, making it possible without additional devices and preparations to assess the result of revascularization in the operating room immediately after surgery. This pilot study allows us to conclude that duplex scanning of the pedal arteries with the measurement of the maximum blood flow acceleration is a promising rapid alternative method of diagnosing peripheral artery disease and assessing efficacy of revascularization performed, especially in patients with uninformative values of the ankle-brachial index and impossibility to measure the finger pressure index.
Carotid endarterectomy is the gold standard for stroke prevention. Although it is one of the most common procedures in vascular surgery, its technique has not been fully standardized. In particular, there is no consensus on the optimal approach for dissection of the carotid bifurcation. Data suggest differences in the safety and efficacy of the retrojugular and/or antejugular approaches, primarily regarding local wound complications and the incidence of cranial nerve injuries, which occur in 1.4-31% of cases and significantly impair patients' quality of life. To compare the safety and efficacy of the antejugular and retrojugular approaches to the carotid bifurcation within a prospective randomized study. The study enrolled 280 patients (140 retrojugular, 140 antejugular). internal carotid artery (ICA) stenosis >70% (asymptomatic) or >50% (symptomatic). primary - pre-existing neurological deficits, reoperations. secondary - perioperative stroke, wound hematomas, early reinterventions. Prospective randomized study. Common complications: perioperative acute cerebral circulatory disorders/transient ischemic attacks - 2.14%/1.43% with antejugular access, 1.43%/0.71% with retrojugular access (p=0.658/0.566); hematomas - 0.7%/2.1%, respectively (p=0.63). Local neurological symptoms: on day 1 - 33.8% (dysphonia - 33.1%, vocal fold paresis - 1.9%), on day 3 - 22.9%, after 3 months - complete regression in all patients. After applying the secondary exclusion criteria, 134 patients with retrojugular access and 132 patients with antejugular access were included in the comparative analysis. The frequency of cranial nerve damage, dysphonia, and dysphagia did not differ depending on the type of access (p>0.05). The surgery time was 76.1±1.8 min (antejugular) vs 74.2±2.4 min (retrojugular, p=0.51). The retrojugular approach facilitates internal carotid artery exposure and obviates venous ligation but does not reduce local neurological complications or operative duration compared to the antejugular approach. Both techniques demonstrate comparable safety profiles, with approach selection contingent on surgeon preference and patient-specific anatomy.
One of the main success factors in the treatment of patients with acute mesenteric ischemia is the timely diagnosis and the earliest possible start of treatment. The aim is to evaluate the diagnostic accuracy and specificity of computed tomography (CT) with intravenous contrast and X-ray contrast angiography in the diagnosis of acute mesenteric circulatory disorders. The work was carried out on the basis of two multidisciplinary hospitals of the third level, which include departments of general surgery and cardiovascular surgery. The study included 93 patients with suspected acute abdominal ischemia. CT angiography was performed in 68 of them, X-ray contrast angiography was performed in 14 of them, X-ray CT preceded endovascular intervention in 8 patients, and acute mesenteric ischemia was detected only intraoperatively after laparotomy in 28 patients after preliminary X-ray contrast examination. The sensitivity of CT angiography was 72.6%, and the specificity was 80.2%. Due to the accuracy and the possibility of detailed visualization of the distal parts of the mesenteric bed, the sensitivity of endovascular interventions was 94.6%, and the specificity was 100%. The use of X-ray contrast angiography is preferable in patients in stable condition with suspected acute mesenteric ischemia, regardless of the severity of changes in the intestinal wall. CT angiography is an accessible and non-invasive research method, it is the primary diagnostic method in patients in order to identify complications of acute mesenteric ischemia, as well as the only method applicable in the absence of endovascular diagnostic methods in the clinic.
The purpose of this study was to compare the incidence of distal embolization during two procedures of restoring blood flow through the superficial femoral artery (SFA): endovascular recanalization and open endarterectomy, both supplemented with paclitaxel-coated balloon angioplasty. Our prospective, randomized, single-center pilot study included 20 patients diagnosed as having extensive occlusions of the SFA. Group 1 patients (n=10) underwent SFA recanalization using percutaneous transluminal angioplasty with a drug-coated balloon (PTA + DCB). Group 2 patients (n=10) underwent semiclosed loop endarterectomy (LE) from the SFA followed by drug-coated balloon angioplasty (LE + DCB). Doppler ultrasonography was used to detect emboli during the revascularization procedure. The patients had no statistically significant differences in age, concomitant pathology, and severity of lower limb ischemia. The majority of patients had Rutherford class 3 chronic limb ischemia. The median number of emboli during the procedure in Group 1 and Group 2 patients amounted to 200.0 [100.0; 200.0] and 7 [6; 8], respectively, p=0.0002. Moreover, in Group 1, peripheral embolism occurred both during recanalization of the target artery (in 100% of cases) and during drug-coated balloon angioplasty (in 60% of cases), whereas in Group 2, peripheral embolism occurred only during drug-coated balloon angioplasty (100% of cases). Endovascular recanalization of long-segment SFA occlusions followed by DCB angioplasty (PTA + DCB) was associated with a higher incidence of material distal embolism compared with the hybrid technique (LE + DCB).
Updating of modern methods of diagnostics and treatment of Budd-Chiari syndrome (BCS), endovascular treatment tactics (balloon angioplasty, TIPS, DIPS, etc.) in order to raise awareness of this pathology among general practitioners, hepatologists, X-ray surgeons and doctors of other specialities. We analysed full-text publications included in the abstract systems eLibrary, Cyberleninka, PubMed, Google Scholar mainly for the last 5 years (69%). The main focus was on diagnosis (ultrasound, CT, MRI) and treatment (anticoagulants, thrombolytics, balloon angioplasty, TIPS, liver transplantation). BCS is a rare disease associated with impaired venous outflow from the liver resulting in suprahepatic portal hypertension. Etiology includes thrombosis, myeloproliferative diseases and congenital vascular anomalies. Epidemiology is variable, with a higher prevalence in Asia. The clinical picture varies from asymptomatic course to fulminant hepatic failure. The main manifestations are variceal haemorrhage and refractory ascites. Without treatment, survival is poor, with fatal outcome occurring within three years. The modern strategy implies a stepwise approach: drug therapy (anticoagulants, thrombolytics), balloon angioplasty, TIPS and radical treatment - liver transplantation. Modern diagnostic methods and staged strategy of BCS have significantly improved treatment outcomes, based on endovascular approach and new technologies (stent grafts, intraoperative use of ultrasound, etc.). However, further research is needed to optimise approaches to early diagnosis and individualisation of therapy.
According to WHO, the number of people suffering from atherosclerotic lesions of the brachiocephalic arteries in different age groups is 20-50%. The development of ischemic stroke with existing chronic occlusion of the internal carotid artery (ICA) occurs with a frequency of 6-15%, and the annual risk of developing acute ischemic disorders in the ipsilateral basin, despite adequate drug treatment, ranges from 6 to 20%. The aim is to evaluate the efficacy and safety of endovascular recanalization in chronic ICA occlusion. The analysis of the first results of intravascular treatment of 12 patients with chronic ICA occlusion on the basis of the vascular neurosurgical department of the Russian Research Neurosurgical Institute named after Professor A.L. Polenov. The age range is from 42 to 75 years (the average age is 57 years). There were 11 men (91.6%) and 1 woman (8.4%). Depending on the type of chronic occlusion, according to the D. Hasan scale (2018), the distribution of patients was as follows: type A (the presence of a proximal ICA stump of the 'candle' type + retrograde filling of the ICA to the stony/cavernous segments) - 4 patients; type B (the presence of a blindly ending proximal ICA stump without the formation of a 'candle' + retrograde filling of the ICA to the rocky/cavernous segments) - 3 patients; type C (occlusion of the ICA from the mouth + retrograde filling of the ICA to the rocky/cavernous segments) - 2 patients; type D (occlusion of the ICA from the mouth with the absence of retrograde filling of the stony/cavernous segments of the ICA) - 3 patients. In 8 (66.6%) of the 12 patients, the ICA lumen was completely restored. According to the D. Hasan scale, type A was noted in 4 patients, type B in 3 patients, and type C in 1 patient. In 4 (33.3%) patients, technical success was not achieved, of which according to the D. Hasan scale: type D was observed in 3 patients, type C in 1 patient. Of the 8 patients with successful ICA recanalization, all underwent remote monitoring by computed tomographic angiography or digital subtraction angiography. No data confirming restenosis were obtained in 6 patients. There were no episodes of recurrent ischemic disorders. In 1 patient, thrombosis of stented ICA was detected against the background of the patient's self-withdrawal of double disaggregant therapy. Unsuccessful recanalization (4 patients), in our opinion, is associated with convolution of the ICA and severe scarring in the lumen of the occluded artery. Intravascular recanalization of chronic ICA occlusion is a promising method that can be effectively used to restore the full-fledged lost artery lumen and normalize brain perfusion to reduce the risks of recurrent ischemic cerebral events.
Cyanoacrylate adhesive сlosure (САС) of subcutaneous veins is a modern method of treating varicose veins of the lower extremities, demonstrating a number of advantages over traditional surgical and thermal ablation techniques. Unlike endovenous thermal сlosure, tumescent anesthesia is not performed in САС, which significantly reduces pain and impact on perivenous tissues, especially for patients with trophic skin disorders. In addition, postoperative compression is not required, which is contraindicated in the presence of obliterating atherosclerosis of the lower extremities. Given the relative novelty of the methodology, the number of studies with long-term results is limited. The aim is to evaluate the long-term outcomes of the use of САС in the treatment of patients with IBD. A retrospective analysis of electronic medical records of patients with IBD has been carried out since the integration of the considered technique into the work of the Phlebology Center of the Multidisciplinary Medical Holding SM-Clinic from 2019 to 2024. The study included patients with varicose-transformed tributaries of the main subcutaneous veins, corresponding to classes C2-C6 according to CEAP, with terminal valve dysfunction with axial reflux (>0.5 s, diameter of the trunk of the subcutaneous vein - 0.6 cm and higher). САС was performed using the VenaSeal Closure System (Medtronic) according to a standard protocol. In the course of the work, demographic and clinical data, key preoperative characteristics (diameter of the target subcutaneous vein, number of venous basins) were evaluated, which were analyzed using descriptive statistics methods. A visual analog scale (VAS) was used to assess the intensity of pain directly during surgery. Postoperative follow-up of patients, including ultrasound duplex scanning, was performed on the 3rd day, then 1, 3, 6 and 12 months after surgery, and thereafter annually. The criterion for the effectiveness of САС was the occlusion of the trunk of the target vein. The safety criterion is the frequency of postoperative adverse events and complications. Evaluation of long-term results with a follow-up period of 5 years was performed in 39 patients who underwent CT in the second half of 2019. 52 lower extremities and 53 venous basins corresponded to this number of patients. There were 24 women (61.5%) and 15 men (38.5%). The average age of the patients was 58.3±16.2 years. 19 (48.7%) patients were elderly and senile. The distribution of patients according to the CEAP classification: C2 - 21 (53.8%), C3 - 15 (38.5%), C4 - 3 (7.7%). The average diameter of the large saphenous vein was 10.8±4.1 mm, the small saphenous vein was 6.7±2.3 mm. In 25 (64.1%) patients, CT was performed on the 1st venous basin, in the remaining 14 (39.5%) - simultaneously on the 2nd venous artery. The average duration of the intervention was 35±25.7 minutes. In 26 patients, САС was performed as an isolated procedure, without intervention on the tributaries and did not require the use of postoperative compression. Simultaneous interventions on tributaries were performed in 13 (33.3%) patients: foam sclerotherapy in 9 (23.1%), miniflebectomy in 4 (10.2%). Intraoperative VAS pain was estimated at less than 3 points in 36 (92.3%) patients. The average VAS score was 2.9±0.7. Immediate technical and anatomical success was achieved in all 39 (100%) patients at the first 2 follow-up examinations (3 days and 1 month after the procedure). In subsequent controls, recanalization was registered in 3 (7.7%) patients. Glue-induced thrombosis was noted in 1 (2.6%) patient. 5 (12.8%) patients had a phlebitic skin reaction (delayed type) that occurred from 1 week to 1 year after surgery. This complication was eliminated by conservative treatment. Tributary thrombophlebitis was recorded in 2 (5.1%) patients. In 1 (2.6%) case, an abscessed soft tissue granuloma was diagnosed at the vein puncture site 5.5 months after the CT scan. Ecchymosis was observed in 4 (10.2%) patients. There were no postoperative neurological complications, pulmonary embolism, or deep vein thrombosis in this group of patients. The incidence of target vein occlusion at 3 months, 6 months, and 3 years after the intervention was 97.5%, 94.9%, and 92.3%, respectively. The last indicator remained until the 5-year observation period. The САС technique demonstrates a high level of efficacy and safety in the treatment of patients with varicose veins of the lower extremities, with a 92.3% occlusion rate of target veins within 5 years after сlosure.
Atherosclerosis of the brachiocephalic arteries is one of the leading causes of ischemic cerebrovascular disorders, which is based on a complex, multi-stage process regulated by epigenetic mechanisms. The latter, in particular, include changes in the expression of molecules such as microRNAs - small (on average, 22 nucleotides) non-coding RNA sequences that are heavily involved in most physiological and pathological processes. The aim of the study was to evaluate the expression of miR-126-5p/-3p, miR-21-5p/-3p, miR-33a-5p/-3p, miR-29a-5p/-3p in relation to association with clinical cerebrovascular events and to identify differences in the expression pattern depending on the performed transluminal balloon angioplasty with carotid artery stenting for hemodynamically significant carotid stenosis. Our prospective study included 80 patients [average age - 66 years, men - 44 (55%)] with cerebral atherosclerosis of varying severity who were admitted to the vascular departments of the 'Research Center of Neurology' (Moscow). Transluminal balloon angioplasty with stenting (TBAS) of the carotid artery was performed in 33 patients [in 14 (42%) patients - for symptomatic stenosis]. All patients underwent thorough clinical and neurological examination, laboratory and instrumental research methods, including isolation and analysis of microRNA expression (miR-126-5p/-3p, miR-21-5p/-3p, miR-33a-5p/-3p, miR-29a-5p/-3p). The microRNA expression pattern was significantly different in the patients who underwent TBAS: the levels of miR-126-5p/-3p and miR-29a-5p were statistically significantly lower, and those of miR-33a-5p/-3p higher compared with the patients who did not undergo angiosurgery. A multivariate linear regression model that included the expression of all the microRNAs studied identified miR-126-5p and miR-21-5p as statistically significant independent predictors of the degree of carotid artery stenosis. The expression of a number of atherogenic microRNAs in patients who underwent transluminal angioplasty with carotid artery stenting appeared to be of a differentiated nature. The most significant biomarker was the expression level of miR-126-5p, which is associated, among other things, with the degree of carotid stenosis.
Methods of endovascular treatment of patients with arterial lesions expand the possibilities for limb salvage. However, one of the main reasons for the reduced long-term effectiveness of these surgical interventions is restenosis. Endothelial-mesenchymal transition is considered one of the reasons for the development of restenosis. The aim was to study the possibilities of predicting the development of restenosis after endovascular interventions on the main arteries of the lower extremities in patients with atherosclerotic peripheral artery disease (PAD) by assessing the levels of endothelial-to-mesenchymal transition biomarkers. The study included 50 patients divided into groups depending on treatment (operative or conservative). The mean age of the patients in the surgical group was 66.1±8.83 years and that in the conservative group 70±8.62 years. The groups were comparable in terms of gender, stage of the disease, side of the lesion, concomitant diseases and baseline values of the ankle-brachial index (ABI). The control group additionally comprised 10 apparently healthy volunteers with neither PAD nor other identified diseases. Peripheral venous blood was collected to assess the level of EndMT markers (endothelial markers - PECAM-1, vWF, mesenchymal markers - vimentin, alpha-Anti-Actin Alpha 2 - antiACTIN, and integral EndMT marker - TGF-b1) in the apparently healthy subjects, as well as patients with stage IIb-IV PAD according to the classification of A.V. Pokrovsky-Fontaine before and after endovascular reconstructive interventions on the arteries of the lower extremities. All patients underwent duplex ultrasonography to assess restenosis at the site of the endovascular interventions performed, with the ABI also determined. Decreased values of the ABI in the post-operative period were associated with elevated levels of vimentin (VIM). Vimentin concentration above 2.98 ng/ml was associated with the development of restenosis 3 months after endovascular surgery. At this stage of the study, it is only possible to assess the role of the mesenchymal parameter vimentin as a potential marker for predicting the development of restenosis after endovascular interventions on lower extremity arteries.
Endovascular thermal ablation techniques, such as endovascular laser or radiofrequency ablation (RFA), have become the standard of care for treating varicose veins. However, some patients may experience unpleasant sensations, such as a 'tourniquet' or 'string', in the area where the subcutaneous artery is obliterated. One way to reduce these adverse events is through the use of topical treatments, such as sodium heparin gel (1000 IU) and a combined preparation containing escin, heparin, and essential phospholipids. The aim of this study was to evaluate the clinical symptoms, frequency, and severity of the 'string' sensation in patients with varicose veins who underwent large saphenous vein ablation (LSVA), and to assess whether sodium heparin (1000 UI) or the combined preparation could alleviate these symptoms. An open, randomized, prospective cohort study was conducted on 180 female patients aged 18-72 years (mean age 41.2±7.5 years) diagnosed with varicose veins of the lower extremities. The patients were divided into three groups: Group 1 underwent IVF without any additional conservative therapy; Group 2 received topical heparin (1000 IU) applied twice daily for two weeks after endovenous thermal ablation (EPR); and Group 3 received a topical medication containing escin, heparin, and essential phospholipids applied twice daily after EPO for two weeks. In the initial class of chronic venous disease, grade 3 according to the CEAR classification, a decrease in edema was recorded at the end of treatment in group 1 in 72.7% of cases, in group 2 - in 76.9% of cases and in group 3 - 91.7%, respectively. The differences between groups 3 (patients receiving a combination topical agent) and the other two were statistically significant (p<0.05). For grade 4 chronic venous diseases, a reduction in dermatitis symptoms was noted in group 3 in 83.3% patients compared to 50% and 57.1%, respectively, for groups 1 and 2. A decrease in induration of tissue was observed in 66.7% of patients in group three compared to 40%, in both group 1 and group 2. Healed ulcerative defects were noted in 60% of group 3 patients versus 33% and 25% in groups 1 and 2, respectively. Using a combination of topical agents, the number of 'string' symptoms decreased from 50.6% to 93.5%. The symptom of 'string' after acute renal failure may occur 2 months after surgery in about 3-4% of patients on average. The use of topical agents containing a combination of venoactive drugs (escin), heparin, and essential phospholipids can help reduce the severity of this symptom.
Conservative management of patients after reconstructive vascular operations remains an important and widely discussed problem of modern medicine. This study was aimed at evaluating efficacy and safety of combined administration of aspirin and low-dose rivaroxaban in patients with atherosclerosis who underwent reconstructive operations on arteries below the inguinal ligament for chronic critical lower limb ischemia. Our prospective cohort study included a total of 182 patients with atherosclerosis and chronic critical lower limb ischemia. The patients' age ranged from 40 to 95 years (mean age 65.3±8.1 years). The period of the study was from 2018 to 2021. All patients underwent femoropopliteal bypass graft surgery with a distal anastomosis both above and below the knee-joint fissure, with either a reversed autovein or a synthetic graft used as a shunt. The patients were divided into 4 groups depending on the type of operation and prescribed therapy in the postoperative period. Control was carried out by means of clinical examination and duplex ultrasound angioscanning of lower-limb arteries after 30 days, as well as at 3, 6 and 12 postoperative months. An unfavorable clinical outcome was defined as the development of either single or various combinations of such conditions as acute limb ischemia, major amputation, shunt thrombosis, acute myocardial infarction, acute cerebrovascular accident, cardiovascular death. They were reveled in the remote period after surgery (from 30 days to 12 month) in 4 (8.3%) Group 1 patients, 6 (13.6%) Group 2 patients, 6 (13.3%) Group 3 patients and in 11 (24.4%) Group 4 patients. Besides, there was 1 (2.6%) major gastrointestinal bleeding in Group 2, with no significant hemorrhagic events revealed in other groups (p=NS). Low-dose rivaroxaban combined with aspirin proved effective in preventing major adverse limb events and safe as to hemorrhagic complications compared with a combination of aspirin and clopidogrel in patients after revascularization of lower extremities for chronic critical limb ischemia.
Stroke continues to occupy a leading position among the causes of mortality in the population. In the Russian Federation, more than 450 thousand cases of acute cerebrovascular accident are recorded annually, with the vast majority (75-80%) being ischemic stroke. Timely restoration of cerebral blood flow allows minimizing the infarction zone by preserving viable areas in the ischemic penumbra, which significantly improves the prognosis of the disease. The aim of the study is to analyze the results of endovascular thrombectomy by direct carotid access in the treatment of patients with ischemic stroke. Within the theoretical section, an analysis of foreign and domestic experience in endovascular treatment of ischemic stroke with complex anatomy was carried out. Within the practical section, the results of our own experience were generalized and analyzed. Over the past 5 years, 613 endovascular mechanical thrombectomies with occlusion in the anterior circulation basin have been performed at the V.V. Veresaev City Clinical Hospital. Of these, 17 patients underwent direct carotid access. The decision on direct access to the common carotid artery was made with unsuccessful selective catheterization of the common carotid artery on the affected side for 30 minutes. Mechanical reperfusion by direct carotid access in combination with systemic thrombolytic therapy was performed in 3 (17.6%) patients. Reperfusion at the TICI-2b-3 level was considered successful. Endovascular reperfusion was successful in 16 (95%) сases. Effective first-pass thrombectomy was performed in 14 (82%) cases. Manual hemostasis after introducer removal was performed in 6 (35.3%) patients, in 11 (64.7%) cases the puncture hole of the common carotid artery was sutured. Symptomatic hemorrhagic transformation was observed in 3 (17.6%) сases. Three patients died. Mortality was 17.6%. The average National Institutes of Health Stroke Scale at discharge was 13.4±6.2 points. In patients with percutaneous puncture, the average time from the beginning of the operation to reperfusion was 62 minutes. Direct carotid access can be considered as an effective and safe method of mechanical thrombectomy in patients with difficult selective catheterization.