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Issue. Articles

2(18) // 2007

 

 

1.

 

The problem of organ protection in the surgery of aneurysm of aortic thoracoabdominal region

Yu.V. Belov, R.N. Komarov, A.B. Stepanenko, A.P. Gens, E.R. Charchian

The purpose of the research was to analyze the effectiveness of the methods of inner organ protection used in the surgery of aneurysm of aortic thoracoabdominal region and to determine which of them are the most efficient.

Material and methods. 100 patients with thoracoabdominal aortic (TAA) aneurysm were operated on during the period of 1995— 2005 at the department of aorta and its branches surgery of the Russian Scientific Centre of Surgery, Russian Academy of Medical Sciences (RAMS). 86.0 % of the patients were men, 14.0 % — women, including: 44 patients (mean age (49 ± 4.6) years) with dissecting aneurysms of aorta (DAA) of III type, 17 (mean age (57 ± 6.2) years) — with chronic TAA aneurysms and 39 (mean age (41 ± 6.3) years) — with descending thoracic aorta aneurysms (DTAA). The following methods of inner organs and spinal cord protection were used: the technique «without perfusion» with catchment of cerebrospinal fluid (WP + CCSF), lateral release of aorta (LRA), left atrium and femoral bypass (LAFB), circulatory arrest and deep hypothermia (CA + DH), bypass grafting with catchment of cerebrospinal fluid (BG + CCSF), partial artificial blood circulation and moderate hypothermia (PABC + MH). The time of aorta crossGclamping, the time of visceral and spinal ischemia and the rate of complication development — paraparesis and acute renal failure (ARF) — were analyzed in both groups of patients.

Results and discussion. Paraparesis occurred in one patient during the operative treatment of chronic TAA aneurysms while using the operative technique without including spinal arteries in the bloodstream. In DTAA patients, in both cases (5.1 %) of paraparesis occurrence, the spinal arteries were not included in the bloodstream, either. The patients with DAA of III type developed paraparesis during longer time of spinal ischemia ((56.5 ± 12.0) min) if compared with mean values ((42.7 ± 4.0) min); however, during LAFB application, paraparesis developed during spinal ischemia of 29 min in spite of the reimplantation of four pairs of spinal arteries. While using CA + DH method in DAA of III type patient, paraparesis was evidently caused by the «excluding» of the false canal of the aorta with artery of Adamkiewicz. Because of unsatisfactory results of WP + CCSF method in TAA surgery (paraparesis and ARF in patients with DAA of III type constituted 5.3 and 7.1 %, respectively, and in patients with chronic TAA aneurysms — 15.7 and 42.9 %), we restricted the indications to its application. One of promising directions of inner organ protection at present is selective antegrade perfusion of visceral arteries in combination with LAFB, which permits the shortening of visceral ischemia to several minutes. We didn't register any substantial differences in paraparesis rate (11.4 and 5.9 %, respectively) (p = 0.46) and multiple organ failure syndrome (25.0 and 41.2 %) (p = 0.24) during the surgical treatment of DAA of III type and chronic TAA aneurysms.

Conclusions. The methods of spinal cord and inner organ protection used in thoracoabdominal aorta surgery are imperfect because they don't permit avoiding complications: paraparesis developed in 5.9 % patients with chronic TAA aneurysms and in 11.4 % patients with DAA of III type; multiple organ failure syndrome — in 41.2 and 25.0 % patients respectively. A promising direction to the decrease of inner organ and spinal cord ischemia in patients with TAA aneurysms is LAFB. While using this method in our research, the rate of paraparesis was on average 0 % vs. 5.9 % in patients with chronic TAA aneurysms and 10.0 vs. 11.4 % on average in patients with DAA of III type, and the frequency of multiple organ failure syndrome — 33.3 vs. 41.2 % and 20.0 vs. 25.0 %, respectively.



Keywords: thoracoabdominal aortic aneurysm, protection of inner organs and spinal cord

2.

 

Evaluation of effectiveness of arterial hypertension treatment: results of one-year clinical examination in Cherkassy region

Yu.M. Sirenko, G.D. Radchenko, V.. Kazmiruk

The aim of this study was to evaluate the effectiveness of routine work on clinical examination of patients with arterial hypertension in the course of one year and to determine the ways of its improvement.

Materials and methods. 1260 patients with elevated arterial pressure (AP) were examined. All of them were residents of villages in Cherkassy region and the city of Cherkassy. During the first and the following three scheduled examinations in the course of one year, all the patients underwent AP and height and weight measurements. They also filled in questionnaires about following the prescribed course of treatment and were given life style modification recommendations. Drug therapy was administered or corrected and methodological materials were given.

Results and discussion. Clinical examination of patients in the course of one year helped to improve the control over systolic AP (SAP) by 15.8 %, over diastolic AP (DAP) – by 20.1 % ( < 0.05). However, only 17.9 % patients had SAP lower than 140 mm Hg and 36.6 % – DAP lower than 90 mm Hg. Among the rural residents, the level of SAP control was lower than among the urban residents – 7.6 % vs. 42.7 % (p < 0.05). Neither the mean body mass index nor the percentages of smokers changed substantially by the end of the study ( > 0.05).

Conclusions. Among the causes of inefficient treatment in our research were: inadequate aggressiveness of antihypertensive therapy (low doses of medications), wrong choice of drugs (administration of short-acting drugs), lack of effective combination therapy, low patient’s baseline compliance to treatment associated with worse AP control at the end of the study. Giving a special «Handbook for patients with arterial hypertension» as written recommendations to patients with low baseline compliance to treatment helped to decrease AP level more substantially.



Keywords: arterial hypertension, arterial pressure control, clinical examination

3.

 

Results of surgical treatment of undiagnosed small abdominal aortic aneurisms in patients with atherosclerotic lesion of aorta-femoral segment

I.V. Arbuzov, Yu.S. Spirin, V.. Arbuzov, R.V. Ivashko

The aim of research was to determine the rate of undiagnosed small abdominal aortic aneurisms in patients with atherosclerotic lesion of aorta-femoral segment and the analysis of the results of their surgical treatment.

Materials and methods. The research was based on the results of treatment of 128 patients with atherosclerotic lesion of aortafemoral segment (AFS) in the period from 2001 to 2006. The estimation of the condition of the abdominal aorta (AA) and the great vessels of the lower extremities (GVLE) was based on the results of ultrasound duplex angioscanning. All the patients underwent AFS reconstructions. In 8 cases of undiagnosed small aneurisms, the resection of AA anterior wall aneurism with the creation of proximal anastomosis between the AA and the synthetic explant (end to side fashion) was performed; in 6 cases — the resection of AA anterior wall aneurism with the creation of proximal anastomosis (end to end fashion) and in 3 cases — the resection of circle AA aneurism with the creation of proximal anastomosis (end to end fashion) were performed. The type of distal anastomosis depended on the degree of GVLE occlusive and stenotic lesion. We studied: the localization and the degree of spread of occlusion; the localization, spread and degree of stricture formation in the lumen of the impaired arterial segment; the presence of thrombotic masses; the presence and spread of calcinosis of the AA and the main arteries of lower extremities.

Results and discussion. During the intraoperative abdominoscopy, we revealed small AA aneurisms in the infrarenal region in 13.3 % cases (17 patients). They changed the character of reconstruction. Intraoperative complications were fixed in two people (11.8 %). In one case we observed iatrogenic lesion of the inferior vena cava and in one case — thromboembolism of femoral arteries with the development of critical ischemia signs. The surgical management strategy in these cases was standard. Positive results were achieved in 94.1 % cases, postoperative mortality was 5.9 %.

Conclusions. The rate of undiagnosed small aneurisms of infra-renal region of the abdominal aorta in patients with atherosclerotic lesion of AFS was 13.3 %. The use of the surgical management strategy suggested by us provided high survival rate during the hospital period (94.1 %) and low rate of intraoperative complications (11.8 %) in such patients.



Keywords: small aneurism, abdominal aorta, surgical management

4.

 

Influence of statin therapy on serum levels of C-reactive protein and matrix metalloproteinase-9 in patients with acute coronary syndrome without ST-segment elevation

V.I. Volkov, T.M. Bondar, L.M. Yakovleva, D.M. Kalashnik

Objective — to determine influence of statin therapy on serum levels of C-reactive protein (CRP) and matrix metalloproteinase-9 (MMP-9) in patients with acute coronary syndrome (ACS) without ST-segment elevation.

Materials and methods. 62 patients with acute ACS without ST-segment elevation were included in the investigation. The duration of the disease didn’t exceed 3 days and the mean age of the patients was (54.8 ± 1.7) years. All the patients were randomized into 2 groups. The patients of I group (n = 33) were treated with standard therapy, in II group (n = 29) simvastatin («Vasilip», produced by KRKA, Slovenia) was added to the standard therapy in the dose of 40 mg/day. The period of treatment was 4 weeks. The group of comparison included 30 coronary artery disease patients with stable exertional angina of III functional class. MMP-9 and CRP serum levels were determined by immuno-enzyme assay.

Results adn discussions. In patients with ACS, the average serum levels of P-9 and CRP were 22.3 % ( < 0.01) and 98.0 % ( < 0.01) higher than in the healthy persons, and 13.3 % ( < 0.05) and 20.0 % ( < 0.05), respectively, higher than in the group of comparison. Positive correlation between CRP and MMP-9 (r = +0.47, p < 0.05) levels was revealed in the patients with ACS. After 4 weeks of treatment, statistically significant decrease of MMP-9 concentration took place only in II group (by 22.7 %, < 0.05), the index being 17.2 % (p < 0.05) lower than in I group. CRP concentration during the observation period decreased by 22.3 % ( < 0.05) in I group and — by 37.7 % ( < 0.01) in II group.

Conclusions. Simvastatin in the daily dose of 40 mg after 4-week therapy has its own anti-inflammatory effectiveness in patients with ACS without ST-segment elevation. MMP-9 participates in the processes of coronary artery disease destabilization and appears to be a more specific marker than CRP for the estimation of simvastatin anti-inflammatory effect.



Keywords: acute coronary syndrome, -reactive protein, matrix metalloproteinase-9, simvastatin

5.

 

Variants of combinations of congenital heart abnormalities with visceral heterotaxia and isomerism of atriums

M.F. Zinkovsky, A.M. Dovgan, R.R. Seydametov, M.Yu. Atamanyuk, S.E. Dykukha, E.V. Satmari, I.G. Yakovenko

In the structure of the congenital heart patalogy there is a very complex group of diseases whose common feature is their combination with visceral heterotaxia, which substantially hampers the surgical treatment of patients with such pathology.

The aim of the work was to determine the kinds of congenital heart lesions combined with the syndrome of visceral heterotaxia and atrial isomerism as well as the rate of their occurrence.

Materials and methods. We studied 61 patients with congenital heart lesions combined with the syndrome of visceral heterotaxia and atrial isomerism. The age of the patients ranged from 10 days to 11 years (mean age 52 ± 43 months). Among them 40 (65.6 %) patients were with univentricular physiology of blood circulation and 21 (34.4 %) — with two ventricles. The examination of the patients included Doppler echocardiography, catheterization of heart cavities and large vessels, X-ray contrast angiography and common clinical methods. The surgical correction of congenital heart lesions was performed in 57 (93.4 %) patients. All the 4 patients who were not operated on died. 12 patients died after the operative intervention. Total lethality was 26.2 %, post-operative — 21.1 %.

Results and discussion. Right atrial isomerism was found in 24 (39.3 %) of patients. In 19 (79.2 %) cases it was combined with univentricular physiology of blood circulation and in 5 (20.8 %) cases there were two full value ventricles. 37 (60.7 %) patients had features of left atrial isomerism. 21 (56.8 %) patients had univentricular heart and 16 (43.2 %) had two full value ventricles. Extracardiac anatomic markers associated with right atrial isomerism are three-lobe lungs, both main bronchi being short (37.5 %), the spleen absence (62.5 %), median location of the liver (33.3 %). The complex of cardiac signs of right atrial somerism includes: total anomalous pulmonary vein drainage (79.2 %), common atrio-ventricular valve (75.0 %), single functional ventricle (79.2 %), pulmonary artery stenosis or atresia (50.0 %), additional left superior vena cava (20.8 %). The main extracardiac signs of left atrial isomerism are: bilateral two-lobe lungs and both main bronchi being long (37.5 %), polysplenia (50.0 %) and biliary tract atresia (25.5 %). Cardiac signs of such isomerism include partial anomalous pulmonary vein drainage (52.4 %), single functional ventricle (56.8 %), azygous continuations of inferior vena cava (40.5 %), coronary sinus absence (32.4 %). Thorough detection of heart lesion complex as part of complex syndrome will make it possible to make adequate tactical decisions, to exclude the factor of unexpectedness during the operation, will provide for the surgeon's readiness to perform non-standard intervention, and, therefore, will improve the consequences of the surgical treatment.

Conclusions. The combination of heterotaxia of visceral organs and atrial isomerism refers to utterly complex syndromes and leads to high total (21.3 %) and post-operative (19.7 %) lethality. The patients with left atrial isomerism are more common and constitute 60.3 %, while those with right atrial isomerism — 39.7 % of the total number. Both variants of atrial isomerism are more common in combination with single functional ventricle: in 79.2 % patients with right atrial and in 56.8 % — with left atrial isomerism. Left atrial isomerism is accompanied by partial anomalous pulmonary vein drainage (52.4 %), azygous continuations of inferior vena cava (40.5 %), coronary sinus absence (32.4 %). Such heart lesions as total anomalous pulmonary vein drainage (79.2 %), common atrio-ventricular valve (75.0 %), pulmonary artery stenosis or atresia (50.0 %), additional left superior vena cava (20.8 %) are associated with right atrial isomerism.



Keywords: atrial isomerism, visceral heterotaxy, congenital heart lesions

6.

 

Specific features of changes of the right and left ventricle systolic and diastolic functions in patients with Q-myocardial infarction involving the right ventricle and their clinical value

E.N. Amosova, O.M. Gerula, Yu.V. Rudenko, I.V. Prudky, V.D. Kudlay

The purpose of the research — to evaluate the peculiarities of the systolic and diastolic dysfunction of the right ventricle (RV) and the left ventricle (LV) in the dynamics of the acute stage of the disease in patients with Q-myocardial infraction (MI) involving both ventricles in comparison with those in MI of only the LV.

Material and methods. We supervised 45 patients with initial MI of the posterior wall (PW) of the LV extended to the RV (I group) and 105 patients with initial isolated MI of the PW of the LV (II group) admitted within the 1st day of the disease. After exclusion of some patients with cardiogenic shock, the number of patients in I and II groups made up 34 and 98, correspondingly. Both groups were comparable as to age (67 ± 1.6 and 65 ± 1.5 years, correspondingly), sex (male 64.7 % and 62.2 %, correspondingly, female 35.3 % and 38.8 %, correspondingly), frequency of arterial hypertension and diabetes mellitus of type 2 with easy course. Thrombolysis and initial percutaneous coronary interventions were applied to 7.6 % and 35.6 % of the patients. Examination covered Doppler echocardiography on the first, seventh through tenth and twentieth through twenty fourth day of the disease when general indices of the systolic function of the LV and the RV (RV diameter (RVD) and shortening fraction (ShF) along the short axis) were evaluated, as well as the indices of transmitral and transtricuspid blood flow with evaluation of the type of diastolic dysfunction of the LV and the RV. Regulatory values of all the indices were received during the examination of 20 practically healthy persons, comparable as to age and sex. Statistical treatment was performed using distribution-free test by Willcockson and Mann-Wittley.

Results and discussion. 11 patients deceased in I group (all having cardiogenic shock), and 7 patients — in II group (5 — of cardiogenic shock and 2 — as a result of the LV rupture). Analysis of indices was executed in patients with no cardiogenic shock. On the first day of MI the patients of the first group manifested more evident as compared to the II group decrease of cardiac index (CI) — (2.5 ± 0.07) vs. (2.7 ± 0.05) l/min/m2, impact index (II) (32.8 ± 0.7) vs. (34.8 ± 0.5) ml/m2 and ejection fraction (EF) of the LV — (46.8 ± 1.0) and (49.7 ± 0.7) %, correspondingly, (all p < 0.05); at the unchanged end-diastolic index (EDI) — (67.9 ± 1.2) and (70.0 ± 0.9) ml/m2, correspondingly, vs. (67.1 ± 1.7) ml/m2 in the control group (all p > 0.05). In the I group of patients, pseudonormal type of diastolic dysfunction of the LV prevailed (68.9 vs. 32.3 % in the II group; p < 0.05), and in the II group — relaxation one (63.8 vs. 6.7 % in the I group; p < 0.05). In the patients of the I group, there was marked increase of the RVD — (2.7 ± 0.1) vs. (2.1 ± 0.1) cm in the II group and (2.1 ± 0.1) cm in the control group and the decrease of ShF of the RV — (30.6 ± 1.3) vs. (33.1 ± 0.9) % in the II group and (34.1 ± 1.0) % in the control group (all p < 0.05). Well-defined systolic dysfunction of the RV (RVD > 2.7 cm and/or ShF < 30 %) in combination with preserved ShF of the LV (> 46 %) and/or with no pulmonary hypertension was marked in 20.7 % patients, and in combination with well-defined systolic dysfunction of the LV and/or pulmonary hypertension — in 15.0 % patients. In most patients (64.3 %) there was no the well-defined systolic dysfunction of the RV. On the seventh through tenth day, the RVD in the I group of patients decreased by 11.1 % and by the twentieth through twenty-fourth day — by 18.5 % (p < 0.05) and became normal. By the twentieth through twenty-fourth day, their ShF of the RV increased by 6.7 %, however it was 3.8 % lower than in the control group (all p < 0.05). The indices of the systolic function of the LV and distribution according to the type of diastolic dysfunction of the LV and the RV in both groups were not changed noticeably in the dynamics of the supervision.

Conclusions. The patients with MI of the LV PW (lower) extended to the RV with no cardiogenic shock on the first day of the disease were characterized by more defined decrease of CI due to the decrease of II as compared to isolated MI of the LV of the same localization. This fact is caused by more substantial systolic dysfunction of the LV with unchanged EDI. MI of the RV leads to the systolic dysfunction of the latter. This dysfunction is accompanied by dilatation of right parts of the heart and the ways of flow and by more defined diastolic dysfunction than in case of isolated MI of the LV. From 7—10th to 20—24th days, the intensity of the systolic dysfunction of the RV decreased progressively in the absence of significant dynamics of the state of its diastolic function.



Keywords: acute myocardial infraction, right ventricle, systolic dysfunction, acute impaired cardiac function

7.

 

Surgical treatment of cardiovascular lesions in case of Marfans syndrome

L.L. Sitar, I.N. Kravchenko

Marfan’s syndrome (MS) is a disease with autosomal and dominant type of hereditability with high penetration of the mutant gene. The disease is characterized with the combination of lesions of the musculoskeletal system, cardiovascular system and the organ of vision. The lesion of the cardiovascular system is usually accompanied by the development of aneurism of the ascending aorta. Only surgical correction of aneurism of the ascending aorta (AAA) and aortal failure makes it possible to prolong the life of this category of patients.

The purpose of the research was to summarize the experience of surgical treatment of aneurism of the ascending aorta in patients with Marfan’s syndrome.

Material and methods. Over the period from 1980 to 2005 inclusive, 194 patients with MS were treated at the Institute. The age of the patients was 7—57 years (mean 31.2 ± 5.6 years). There were 73.7 % men and 26.3 % women among them. The diagnosis was based on the data of the clinical and X-ray examination, data of transthoracic and transesophageal echocardiography, computer tomography and aortography. 14 out of 29 patients who had not been operated on died of aneurism rupture, other 4 — of heart failure. 165 (85.1 %) patients were operated on, 139 (84.2 %) of them underwent Bentll — De Bono operation.

Results and discussion. Hospital lethality in general constituted 13.9 %, after Bentll — De Bono operation — 12.9 %. The main causes of death were hemorrhage, acute cardiovascular failure, acute impairment of the cerebral blood circulation, acute renal failure. The long-term results of 62.0 % patients was good, of 15.7 % — satisfactory, of 8.3 % — unsatisfactory; 14.0 % patients died in the long-term period.

Conclusions. According to our experience of surgical treatment of the ascending aorta aneurism in 165 patients with Marfan’s syndrome, the operation of choice is Bentall-De Bono operation. Its improvement, which we suggested by way of fixing the conduit through teflon strips and applying a shunt between the paraprosthetic space and the right atrium at the place of their direct conformity, made it possible to lower the risk of massive hemorrhagic complications from 15.0 to 0.8 %. The main causes of severe complications and death of patients in the remote periods after the operation of Bentll — De Bono type are the formation of false aneurisms in the zone of anastomoses (4.7 %; according to literature data — to 25.0 %), the development of infectious endocarditis (3.8 % and 10.0 %, respectively) and the spread of exfoliation on the descending thoracic and abdominal aorta (1.9 % and 29.0 %). That’s the reason why lifelong regular medical check-ups of patients who have undergone the operation are advisable.



Keywords: Marfans syndrome, aneurism of the ascending aorta, exfoliation

8.

 

The diagnosis of multi-focal atherosclerosis in patients with chronic critical ischemia of lower extremities

V.G. Mishalov, V.A. Cherniak, M.P. Boichak, L.Yu. Hladka, V.Yu. Zorhach, L.Yu. Markulan, V.M. Seliuk

The purpose of the research was to determine the rate of multi-focal atherosclerosis of different basins in patients with chronic critical ischemia of lower extremities by means of the diagnosis algorithm which was designed by us and to prove the advantages of this algorithm.

Materials and methods. We examined 1187 patients with the diagnosis of chronic critical ischemia of lower extremities (CCILE) based on the criteria of the European consensus on critical ischemia. Retrospective and prospective analyses of the results of multifocal atherosclerosis (MA) diagnosis were conducted in two groups of patients with CCILE. Group A consisted of 593 (49.96 %) patients who were examined using the standard algorithm of MA diagnosis. Group B was composed of 594 (50.04 %) patients for whom we applied the diagnosis algorithm which was designed by us and complemented by functional research methods aimed at revealing «hidden» ischemia in the most important arterial basins: coronary, brachiocephalic, intestinal and spinal.

Results and discussion. was diagnosed in 372 (52.6 %) patients of group A and in 518 (87.2 %) patients of group B. Among the patients of group A, two-basin lesions were revealed in 319 (53.8 %), three-basin — in 41 (6.9 %), four-basin — in 10 (1.7 %), five- and more basin lesions — in 2 (0.3 %). Among the patients of group B, two-basin lesions were revealed in 248 (41.8 %), threebasin — in 194 (32.7 %), four-basin — in 56 (9.4 %), five- and more basin lesions — in 20 (3.4 %; < 0.05). In group B, the number of revealed combined atherosclerotic lesions in different arterial basins was 884 versus 439 in group A ( < 0.05). The analysis of the basins showed that the increase of rate of revealing combined atherosclerotic lesions in the patients of group B results from the use of the new diagnosis algorithm in coronary, brachiocephalic, intestinal and spinal arterial basins. The rate of revealing coronary artery disease (CAD) in group B was higher at the level of statistical significance ( = 0.001) than in group A and constituted 61.6 and 18.9 %, respectively. Similar tendencies were traced in other arterial basins, too.

Conclusions. Multi-focal atherosclerosis in patients with chronic critical ischemia of lower extremities was revealed in 87.2 % patients using the diagnosis algorithm suggested by us and in 62.7 % — in case of using the standard algorithm ( < 0.05). The research algorithm designed by us made it possible to improve at the level of statistical significance the diagnosis of three-, four-, five- and more basin lesions due to revealing «hidden» ischemia in coronary ( = 0,0001), brachiocephalic ( = 0,0001), intestinal ( = 0,001) and spinal ( = 0,0001) arterial basins. The most common combined lesions in patients with chronic critical ischemia of lower extremities of group B are coronary (61.6 %), brachiocephalic (36.2 %), intestinal (21.9 %) and renal (10.4 %).



Keywords: multi-focal atherosclerosis, chronic critical ischemia of lower extremities, combined lesions, diagnosis algorithm

9.

 

Complications of the long-term endovascular stent grafting of the aorta abdominal region aneurism

S.M. Volodos

The progress of the development of low-invasive methods of treatment and endovascular surgery in particular made endovascular stent grafting of the aorta abdominal region aneurism possible. The clinical use of the method is inevitably accompanied by the development of complications which, as a result of their study and systematization, have been divided into three groups. The fist group comprised so called basic complications: dislocation of the endoprosthesis, including the disconnection of parts of module prostheses; blood leak into aneurismal sack; elevated pressure in the aneurismal sack. The second group comprised complications connected with the constructive features of endoprostheses: kinking of endoprostheses, thromboses of their lumens, ruptures of the membrane material and mechanical lesions. The third group comprised common complications: kidney dysfunction; neurological complications; bedsores of the neighboring organs and tissues; intestinal ischemia; distal embolisms of the arterial bed; infectious complications. The prophylaxis of endovascular stent grafting complications is primarily determined by the understanding of the mechanisms and factors of their occurrence. The mechanisms of the development of endovascular stent grafting complications are often interconnected. Short arched aortal neck, presence of a mural thrombus in it, further widening of the aortal neck decrease the safety of the endoprosthesis fixation and increase the probability of its displacement and blood leak. Variants of fixation of an uncoated or fenestrated region of the endoprosthesis on the level of the renal arteries or in the adrenal region of the aorta are used at present. The techniques which make it possible to make prosthetic appliances of the renal arteries separately in cases when there is no aneurism of the neck, are under study now. Many authors consider the use of endovascular methods in treating endoprosthesis complications appropriate. Thrombosis of the endoprosthesis can be removed by means of thrombolytic therapy with further endovascular correction of the defect. In case of performing an open surgical intervention the endoprosthesis usually remains at its place. It is additionally fixed or corrected in some other way. At present, we fix decreasing number of complications of the endovascular stent grafting of the aorta abdominal region, which makes this method still more attractive for wide practical use. An important index of the effectiveness of this method is a small number of aneurism ruptures after performing endovascular stent grafting (0.49 %).



Keywords: aneurism of aorta, endovascular surgery, complications

10.

 

Right ventricle infarction

V.I. Tseluyko, N.E. Mishchuk

This review presents data concerning epidemiology, pathophysiology, clinical picture, diagnosis and treatment of myocardial infarction (MI) of the right ventricle (RV). It is emphasized that MI RV with hemodynamic signs is usually combined with widespread posterior and inferior MI of the left ventricle (LV). In case of such localization of the latter, the frequency of the lesion of the RV reaches 30—50 %. The isolated lesion of the RV is revealed during the autopsy in less than 3 % cases. As a rule, MI RV occurs in case of proximal occlusion of the dominant right coronary artery (RCA) and is combined with MI of the inferior wall of the LV. In case of nondominant RCA occlusion, the development of isolated RV infarction was documented. MI RV with hemodynamic signs is characterized by severe right ventricular failure, «clean» lungs and low cardiac ejection in the presence of relatively preserved global systolic function of the LV. Paradoxical pulse and Kussmaul’s sign are also considered to be typical clinical manifestations; right ventricular III and IV tones, the noise of three-valve regurgitating are revealed during the auscultation. Noninvasive diagnosing of MI RV presupposes conducting ECG, echocardiography (EchoCG), roentgenography of the thorax organs, radionuclide ventriculography (RVG) and scintigraphy of the myocardium with 99m. We considered the strategy of MI RV treatment based on the following principles: 1) reperfusion of myocardium; 2) optimization of the RV pre-loading; 3) inotropic support; 4) optimization of the heart rhythm. It is emphasized that all the patients are recommended early reperfusion, exclusion of vasodilators and diuretics from the therapy, volume loading in case of hemodynamic impairments, inotropic support, optimization of the rate in case of bradycardia and atrioventricular heart block, restoration of the sinus rhythm.



Keywords: right ventricle, myocardial infarction, epidemiology, pathophysiology, diagnosis, treatment

11.

 

Fallots tetralogy Part I

V.B. Demyanchuk, V.P. Zakharova

The right ventricle functions under conditions of permanent pressure overload in tetralogy of Fallot. Therefore the hypertrophy of the right ventricle myocardium is obligatory part of this defect. The question of the right ventricle hypertrophy in tetralogy of Fallot is relevant because the hypertrophy grows progressively worse with course of time. Some modern concepts of age-related evolution of structure of the right ventricle myocardium and its possible consequences are represented in the manuscript. These data can be considered as additional arguments for early correction of tetralogy of Fallot during the first years and even months of life in order to avoid of irreversible changes of myocardium and to improve short- and long-term results of surgical treatment.



Keywords: tetralogy of Fallot, right ventricle of heart, myocardial hypertrophy

12.

 

Chronic venous insufficiency

S.N. Genyk

Modern seeing of the pathogenesis and approach to treatment of chronic venous insufficiency (CVI) were analyzed in the article. Because of its high prevalence this pathology is called "the illness of civilization". The increase of the vein bed area in case of varicose illness and its decrease in case of posttrombophlebitis syndrome unites these two opposite states. Making the diagnosis more accurate and defining the character of the venous system lesion more exactly are possible due to functional tests and instrumental methods of study: duplex scanning, Doppler ultrasonography, phlebography, radionuclide phleboscintigraphy, photoplethysmography, volumetry, dynamic phlebotonometry, thermography. The basic method of CVI treatment is operation — selective phlebectomy. Intraoperative or postoperative sclerotherapy of the varicose-changed veins substantially reduces the volume, traumatism and duration of the intrusion.



Keywords: chronic venous insufficiency, varicose veins, vein thrombosis, trophic ulcers

Current Issue Highlights

4(60) // 2017

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K. M. Amosova 1, I. I. Gorda 1, A. B. Bezrodnyi 1, G. V. Mostbauer 1, Yu. V. Rudenko 1, A. V. Sablin 2, N. V. Melnychenko 2, Yu. O. Sychenko 1, I. V. Prudkiy 1&a

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