ENDOVASCULAR AND OPEN SURGICAL OPERATIONS OF CRITICAL ISCHEMIA OF THE LOWER EXTREMITIES

В отделении сосудистой хирургии на протяжении 40 лет (с 1972 по 2012 гг.) было выполнено 9800 открытых операций у больных с КИНК II-IIIст, клинические результаты которых представлены в соответствующем разделе статьи для сравнительного анализа. В основном разделе работы рассматриваются результаты эндоваскулярных хирургических и открытых операций, выполненных у 1088 больных с критической ишемией нижних конечностей II-IIIст (КИНК) и сахарным диабетом (СД). Проведен сравнительный анализ показателей частоты ампутаций при открытых и эндоваскулярных хирургических вмешательствах (ЭХВ). Установлено преимущество ЭХВ в сравнении с открытыми операциями на основании снижения числа ампутаций после выполненных ЭХВ соотвественно с 52,3% до 3,5%. In the department of vascular surgery, for 40 years (from 1972 to 2012), 9800 open operations were performed in patients with CLI II-IIIst, the clinical results of which are presented in the corresponding section of the article for comparative analysis. The main section of the work examines the results of endovascular surgical and open operations performed in 1088 patients with critical ischemia of the lower extremities II-IIIst (CLI) and diabetes mellitus (DM). A comparative analysis of indicators of the frequency of amputations during open and endovascular surgical interventions (ECS) was carried out. The advantage of ECV in comparison with open operations was established on the basis of a decrease in the number of amputations after ECV performed, from 52.3% to 3.5%, respectively.

EARLY REHABILITATION OF CRITICAL TESTICULAR ISCHEMIA WITH ACUTE TORSION IN CHILDREN

Introduction. Acute testicular torsion is an urgent condition characterized by chorda spermatica turn and torsion with its vessels along vertical or horizontal axis. This condition results in testicular ischemia and loss of organ in case of lack of timely medical care. If a child is operated on within 6-12 hours their chance for complete recovery is decreased to 70 %. The timeline of 12-24 hours leaves only a 20% chance to keep a testicle. After 24 hours since the beginning of the condition there is virtually no chance to keep organ’s viability. The goal of the research is an optimization of early rehabilitation of critical testicular ischemia in children with acute testicular torsion. Material and methods. Over the period of the years 2010 – 2021 54 children with testicular torsion were observed and treated. Eight children got to a hospital as in-patients within first six hours from condition establishment, eight patients turned to a hospital within the period of 6.1-12 hours, 11 patients addressed hospital after 12.1-16 hours, 16 patients did so after 16.1-24 hours, and 11 patients addressed hospital after more than 24 hours since condition had been established. All patients with testicular torsion were admitted to a hospital in an urgent manner, their general condition was assessed as "moderate". Time before surgery was limited (up to 1 hour from the moment of hospitalization). Therefore, the examination of patients was minimized by a general blood test, a general urine test (83.3 %), determination of blood group and Rh-factor, measuring arterial pressure. A testicle was verified as viable in 12 children (22.2 %). Genital gland necrosis was diagnosed in 22 patients (40.8 %), they underwent orchophuniculectomia. Critical testicle ischemia was diagnosed in 20 boys (37 %). All patients were operated on. In all cases operation started not later than an hour after hospitalization. For 45 children operation was performed via inguinal access (83.3 %), transscrotal access was used in 9 patients (16.7 %). In all cases when a testicle was viable invasive detorsion with further orchiopexy was used. All children who underwent testiculectomy were hospitalized later than 16 hours after the onset of the disease. All boys with critical testicle ischemia underwent rehabilitation measures during operation. Results. Among children with genital gland critical ischemia 10 patients (52.6 %) recovered completely. Children who had been hospitalized during 6-12 hours after the onset of the disease were discharged from a hospital ward on the 5-7 day after operation. Two children (25 %) in this group had further testicle autolysis. Among children who addressed for healthcare support within 12–16 hours after the condition establishment, two patients (18.2 %) recovered completely. Five patients (50 %) had testicle autolysis in the postoperative period. Conclusions. 1. Critical testicular ischemia is observed in 35.2 % children with acute testicular torsion. 2. Early rehabilitation measures include a complex of conservative and operational approaches implemented in pre-operational, intra-operational and early post-operational periods. 3. Timely and full-fledged rehabilitation measures implementation allows to improve results of operational treatment and save affected genital gland with critical ischemia in 50 % of patients.

Epidemiological Analysis of Lower Limb Revascularization for Peripheral Arterial Disease over 12 years in the Public Health System in Brazil

Objectives: Worldwide, peripheral arterial disease (PAD) is a disorder with high morbidity, affecting more than 200 million people. Our objective was to analyse the surgical treatment for PAD performed in the Unified Health System of Brazil over 12 years based on publicly available data. Methods: The study was conducted with data analysis available on the DATASUS platform of the Brazilian Health Ministry, assessing procedure technique distribution throughout the years, mortality and cost. Results: A total of 129,424 procedures were analysed (either for claudicants or critical ischemia, proportion unknown). The vast majority of procedures were Endovascular (65.49%), with a tendency for increase in this disproportion (p<0.001). There were 3,306 in-hospital deaths (mortality of 2.55%), with lower mortality in the Endovascular group (1.2% vs. 5.0%, p=0.008). The overall governmental investment for these procedures was U$ 238,010,096.51, and Endovascular Procedures were on average significantly more expensive than Open Surgery (U$ 1,932.27 v. U$ 1,517.32; p=0.016). Conclusions: In the Brazilian Public Health System, lower limb revascularizations occurred with gradual growing frequency between 2008 and 2019. Endovascular procedures were vastly more common, and related to lower in-hospital mortality rates, but higher procedural costs.

Auto-venous femoral-popliteal bypass in patients with critical lower extremity ischemia and coronary heart disease associated with diabetes melitus

Аim — to improve the results of treatment of patients with atherosclerotic lesions of the arteries of femoral-popliteal segment, who underwent auto­venous femoral-popliteal bypassgrafting.Materials and methods. During the period of years 2018 to 2021, 34 patients with critical ischemia of the lower extremities underwent autovenous shunting with a reversed great saphenous vein with treatment of the inner surface of the vein with a solution of cytostatics (paclitaxel). Besides, the treatment was analysed in two control groups, who underwent autovenous reverse vein shunting (30 patients) and autovenous in-situ shunting (33 patients). The follow-up periods lasted for 24 months. The evaluation criteria included the cases of shunt thrombosis, shunt stenosis, mortality, serious ischemic events — acute lower extremity ischemia, myocardial infarction, ischemic stroke, cases of high amputations of the lower extremities.Results. In the postoperative period, no deaths were observed; absence of complicationswas registered in 96 (98 %) patients. In the main group, the frequency of shunt thrombosis was 5 (14.7 %), hemodynamically significant restenosis was diagnosed in 6 patients (17.6 %), acute myocardial infarction in 1 patient (2.9 %). In the comparison group, 11 cases of autovenous shunt thrombosis were defined.Conclusions. Our clinical experience showed promising short- and medium-term results. The chosen surgical approach and topical application of cytostatic drugs enabled to achieve long-term patency of venous shunt, which is of particular importance for patients with diabetes mellitus.

Hybrid vascular interventin for multilevel peripheral arterial disease

Objective To increase the effectiveness of intervention for the lower limb arteries multilevel lesion (MPAD) in patients with type C and D lesions by TASC II classification. Materials and methods 87 hybrid vascular reconstructions (74 male and 13 female, 59% (n=52) smokers) for MPAD were performed from 2017 to 2020. The average age was 64,6±8,1y. CLI was diagnosed in 47% (n=41) by Fontaine- Pokrovsky classification. Following concomitant disease were diagnosed: stage 2–3 of CHF by HYHA classification 33% (n=29), COPD 23% (n=20), arterial hypertension stage 2–3 54% (n=47), CAD 66% (n=58), postinfarction cardiosclerosis 29% (n=26). Registered lesion of iliac-femoral segment type A/B=44 (51%) and C/D=43 (49%); registered lesion of femoro-tibial segment A/B=14 (16%), C/D=73 (84%) by TASC-II classification. Common femoral artery (CFA) bifurcation was most important to perform hybrid intervention. Through CFA with patented method (RU 2621395C) we performed remote endartherectomy from external iliac or superficial femoral arteries, that allowed us to remove a total prolonged occlusion (&gt;15–20 cm), reducing the time and complexity of the endovascular stage. The key note is that we perform CFA plasty with using an autovenous patch with a “trunk” through which we provide endovascular stage of hybrid intervention on natural blood flow, restored after open endartherectomy. This technique allows you to change the direction of introducer in both distal and proximal direction without the need for extra punctures or temporary clamping of the arteries. Results Technical success rate was 98%. Local aneurysm of EIA was found in one case that restricted to provide the loop endarterectomy. The average duration of hybrid operation was 223,7±88,2 min (134,2±72,3 min for open and 89,9±52,9 for endovascular stages). Average blood loss was 225,3±130,7 ml. ICU staying duration was 20,6±2,8 hours. 30-days patency was 98,8%, 12 and 36 months primary patency was 98% and 88,5% respectively. There were no deaths within 30 days after hybrid operation. The following complications occurred: bleeding n=2 (2,3%), acute thrombosis n=1 (1,2%), surgical site infection n=1 (1,2%) but cured safely. Limb salvage in critical ischemia was in 100% of patients for 20 months. Conclusion Hybrid surgery of MPAD is highly effective, reduces operation trauma, improves its results and limb salvage. By reducing trauma of surgical intervention reduces admition in ICU, postoperative risks, especially in patients with severe concomitant pathology. FUNDunding Acknowledgement Type of funding sources: None.

Combined Correction of Experimental Critical Ischemia of the Lower Extremities in a Rat Model

The purpose of our research was to study the effectiveness of correcting experimental critical ischemia (CI) of the lower extremities with a combination of udenafil, simvastatin, and autologous bone marrow mononuclear cells (ABMMC). Methods and Results: The experiments were carried out on 24-month-old Wistar rats, weighing 220–250g. The animals were randomized by sex and weight. Groups were formed according to the manipulations carried out during the operations. The animals were divided into 7 groups, each with 20 animals: Group 1 included intact animals; Group 2 - falsely operated animals; Group 3 (control group) - animals with simulated CI without treatment; Group 4- animals with CI and monotherapy with udenafil (daily oral administration of 8.6mg/kg for 28 days); Group 5 - animals with CI and simvastatin monotherapy (daily oral administration of 1.71mg/kg for 28 days); Group 6 - animals with CI and monotherapy with ABMMC (parenterally, once on Day 7 after modeling CI, 50μl at 4 points and, paravasally, above the inguinal ligament in the area where the lateral artery leaves the artery enveloping the femur from the internal iliac artery; in the area of the superficial artery that bends around the iliac bone under the inguinal ligament; into the area of origin of the muscular branch of the femoral artery r. muscularis, the place of attachment of the comb and long adductor muscles of the thigh; in the upper third of the gastrocnemius muscle]); Group 7 - animals with CI and combination therapy (udenafil and simvastatin drugs were administered intragastrically 0.86 mg/kg, once a day, for 7 days) and one-time parenteral administration of ABMMC, according to the same scheme as in Group 6. On Days 21 and 28 of the experiment, the level of blood microcirculation was determined in the muscles of the rat leg; for this, laser Doppler flowmetry was used. For further morphometric assessment of the leg muscles, they were removed. Preparations for morphometric analysis were prepared according to the standard technique with Van Gieson staining, as well as H&E. Our study demonstrated the effectiveness of combination therapy with udenafil, simvastatin, and ABMMC to correct critical lower limb ischemia in rats. The severity of morphological changes on the background of this combination was minimal, compared to the findings of other study groups, and the level of blood microcirculation in the ischemic zone on Day 28 was, significantly, 1.9 times higher than in animals of the control group. The results obtained allow us to recommend the use of the investigated combination (udenafil+simvastatin+ABMMC) for the treatment of patients with critical limb ischemia, both in outpatient and inpatient practice.

Results of infrainguinal reconstructions with distal anastomosis below the knee joint fissure in patients with critical ischemia when using various prosthetic materials

Aim. To cоmpare the results оf infra-spinal reconstructions of the lower extremities with the formatiоn of a distal anastomоsis below the knee joint fissure with the use of a bioprosthesis and autovein in critical limb ischemia (CLI).Methods. The hospital results of revascularization were retrospectively analyzed in 53 patients with CLI who underwent primary prosthetics of the femoral-popliteal segment with the fоrmation of a distal anastomоsis belоw the knee joint gap. All patients, depending on the prоsthetic material used, were divided into two groups: 1) autovein was used as a prosthesis (39.6%, n = 21)) and 2) a bioprosthesis was used (“KemAngioprosthesis” closed joint-stock company “NeoCor” Kemerovo, Russia) (60.4%, n = 32).Results. In the early postoperative period, thrombosis developed in group 1 in 7 cases (33.3%): in 5 patients – on the first day after the surgery; 2 out of 5 patients were with chronic arterial insufficiency (CAI) of the fourth degree, 1 was with acute arterial insufficiency of the first degree, and 2 patients with the third degree of CAI. In group 2, there were 6 prosthetic thrombosis (18.7%), 4 cases of which developed thrombosis on the first day, 3 patients with CAI of the fourth degree and 1 case with acute arterial insufficiency of the second degree.Conclusion. The application of infra-lingual reconstructions using bioprostheses is quite effective and safe in patients with CLI, in particular with purulent-necrotic trophic processes when a suitable autovein to be used as a prosthetic material is absent.

POTENTIAL AND PERSPECTIVES OF INDIRECT REVASCULARIZATION IN TREATMENT OF LOWER LIMBS CRITICAL ISCHEMIA

This review was undertaken by a literature search of the International scientific database PubMed and Cochrane library. The review highlights the issues and perspectives of indirect revascularization in the patients with lower limbs critical ischemia. The study revealedthat lower limbs critical ischemia remains the actual problem ofangiosurgery, despite of the widespread introduction of angioplasty and open vascular reconstruction. However, angioplasty and bypass surgery revascularization cannot be performed in some category of patients, so that the further improvement of indirect revascularization techniques has been of great interesttoresearchers. The severity of the ischemic process is determined not only by the mechanical blood flow restriction but also by the angiogenic potential of the surrounding soft tissues, foremost muscular one. Therefore, in the case of technical irreparability of the main blood flow it remains possible to preserve the limb by creating new vascular networks in the muscular tissue. Revascularizing osteotrepanation of the lower limb bones is considered to be theoptimal variant to achieve this result. The discontent of clinical outcomes occurred due to the slow development of the angiogenic effect, which in critical ischemia is fraught with loss of a limb until the maximal angiogenesis is reached. In recent years, cell therapyhas become a very promising and advanced scientific research topic. So that its methods have been actively introduced into practice; they are easily combined with revascularizing osteotrepanation and are able significantly accelerate angiogenesis induced by surgical bone injury. In this regard, there is reason to believe that curative effect increases when revascularising osteotrepanation is combined with cell therapy, including the use of bone marrow aspirates.