[The use of oscillatory respiratory therapy with positive expiratory pressure (PEP-therapy) to restore the functional state of the lungs in patients after cardiac surgery]

Postoperative pulmonary complications in cardiac surgery patients occur in 10-35% of cases, depending on differences in their definition, patient characteristics and type of surgical intervention, most of them are associated with ineffective coughing and evacuation of bronchial secretions.

OBJECTIVE

To determine the effectiveness of stimulating the evacuation of bronchial secretions with the help of oscillating PEP therapy carried out during the first three days.

MATERIAL AND METHODS

A randomized prospective study of 60 adult patients after elective cardiac surgery was performed (Clinical Trials.gov. protocol number NCT05159401). Oscillatory PEP-therapy was performed in 30 patients using Acapella DHGreen device (SmithMedicalASD, USA) 10-12 hours after tracheal extubation 3 times a day for 3 days after surgery. The control group (30 patients). The inclusion criteria: age over 18 years, spontaneous breathing after tracheal extubation, clear consciousness and productive contact with the patient, the ability to maintain adequate gas exchange on the low-flow oxygen inhalation, adequate analgesia (<2 points of VAS). Exclusion criteria: the need for re-intubation and mechanical ventilation, non-invasive mask ventilation, high-flow oxygen therapy, acute cerebrovascular accident, ongoing bleeding, cardiac insufficiency (inotropic index >10), shocks syndrome of various etiologies, the use of any extracorporeal support, any neuromuscular disorders, pneumothorax, hydro-or hemothorax. Before each session and 20 minutes after its end, when breathing air, blood oxygen saturation was recorded using a pulse oximeter (SpO2), the maximum inspiratory capacity (MIC) was measured using a Coach-2 incentive spirometer from SmithsMedical and spirometry with a portable ultrasonic spirometer Spiro Scout (Schiller, Switzerland). For the purposes of this work, the total index of the spirometry maximum inspiratory capacity (SMIC) was used - the sum of the respiratory volume and the reserve volume of inspiration in ml.

RESULTS

Difficulties in evacuation of sputum were noted in 90% of patients. Three-day sessions of oscillating PEP- therapy are accompanied by a significant improvement in the passage of sputum, as evidenced by a 3-fold increase in the number of patients with productive cough. The increase in MIC in the main group was 46.9% and 21.3%, respectively (p=0.042), and the number of patients with values greater than MICo. 1500 ml increased from 23.3% to 7.6% (p<0.001). The effectiveness of oscillatory PEP-therapy is confirmed by a 7-fold decrease in the frequency of radiological changes in the lungs at the end of sessions (p<0.001), while in the control group the frequency of their occurrence practically did not change and remained at a high level. The total number of patients with respiratory insufficiency (SpO2≤92%) decreased by 8.6 times after completion of all PEP- therapy sessions (p=0.001), however, without statistically significant difference with the control group.

CONCLUSIONS

Oscillatory PEP- therapy in cardiac surgery patients has a positive effect on sputum passage, ventilation parameters and oxygenating lung function. The procedure was well tolerated and there were no complications associated with it.

Aortic arch debranching in hybrid thoracic aortic replacement

OBJECTIVE

To analyze the outcomes of aortic arch debranching in hybrid thoracic aortic replacement.

MATERIAL AND METHODS

There were 107 patients who underwent hybrid thoracic aortic repair with debranching of supra-aortic vessels between 2015 and 2021. Patients underwent total and partial debranching (subtotal debranching and subclavian-carotid anastomosis/bypass). Debranching was performed in patients with type 3 dissection, type B aneurysms, post-traumatic aortic isthmus and arch aneurysms, thoracoabdominal aneurysms type A and DeBakey type 1 dissections.

RESULTS

One patient (0.9%) died from thoracic aorta rupture after retrograde dissection. There was a moderate decrease of blood flow velocity through the left vertebral artery after subtotal debranching without severe hemodynamic disorders. Despite mild surgical trauma, subtotal and especially total debranching are characterized by higher risk of thrombosis of branches with potential fatal outcomes. In young patients requiring subtotal aortic arch debranching, open reconstruction or repair with fenestrated stents is preferred. We recommend a Bavaria type II hybrid procedure for patients with high surgical risk. In our opinion, more physiological hybrid interventions with anatomical arrangement of supra-aortic vessels such as Elephant Trunk and Frozen Elephant Trunk procedures are preferred.

[Surgical treatment of DeBakey type 1 aortic dissection]

The article is devoted to the founder of Russian Research Center for Surgery, academician B.V. Petrovsky, who created a multi-field surgical institution of the highest world standards. Treatment of thoracoabdominal aortic aneurysms and dissections being the most difficult and laborious has been solved at the Russian Research Center for Surgery from initial procedures to the most difficult hybrid interventions and total aortic repair.

[Subclavian-carotid replacement in chronic cerebrovascular insufficiency management]

AIM

To present own experience of subclavian-carotid replacement for chronic cerebrovascular insufficiency management.

MATERIAL AND METHODS

For 12 years 7 subclavian-carotid reconstructions were performed that was 1.2% of all carotid repairs during this period. Great saphenous vein was always used as a graft. Carotid endarterectomy from proximal internal carotid artery was additionally performed if it was necessary. Patients had severe advanced lesion of supra-aortic vessels including bilateral carotid lesion and significant stenosis of ipsilateral proximal common carotid artery. The vast majority of them had cerebrovascular insufficiency grade 3-4.

RESULTS

All patients underwent surgery without significant complications despite initially severe state due to advanced lesion of brachiocephalic arteries. Long-term postoperative patency of the grafts was satisfactory within the period from 12 years to 1.5 months. There were no neurological impairment and stroke.

CONCLUSION

Subclavian-carotid grafting is an effective alternative for carotid endarterectomy in patients with advanced atherosclerotic lesion of common and internal carotid arteries.

[Angina Recurrence After Coronary Artery Bypass Grafting Caused by the Coronary-Subclavian Steal Syndrome]

We present two cases of surgical treatment of patients with coronary artery steal syndrom and multifocal atherosclerosis, who previously underwent coronary artery bypass grafting using left internal mammary artery. In both cases carotid-subclavian bypass was performed through supraclavicular access using synthetic prosthesis. This method allowed to restore blood flow in the left internal mammary artery, eliminate recurrent angina pectoris, and improve patients quality of life. The article also contains descriptions of possible methods of surgical correction of this pathology, their advantages and disadvantages.

Nitinol clips sternal osteosynthesis after heart/great arteries surgery as a method for prevention of postoperative complications

The problem of sternal osteosynthesis after cardiac surgery is relevant because of a relatively high incidence of postoperative complications associated with inadequate sternal consolidation. The use of nitinol clips is one of the reliable and versatile methods of sternal osteosynthesis. Our research included 208 postoperative patients with different cardiac surgical pathologies. All interventions were carried out with cardiopulmonary bypass using median sternotomy. Patients were divided into 2 groups according to sternal fixation methods: group 1 (105 patients) - wire suture osteosynthesis, group 2 (103 patients) - nitinol clips closure. The short-term postoperative results were analyzed by using the major criteria for comparison. Radiographically confirmed varying degrees of sternal defects in the immediate postoperative period were observed in 15.2% of patients in group 1 and 3.8% of patients in group 2. In group 1 significant sternal defects requiring sternal refixation were observed in 4.8% of patients; in group 2 no such cases were identified. The mean blood loss in the drainages for 24 hours after surgery in group 1 was 351 65 ml; in group 2 - 192 43 ml. The total number of resternotomies for bleeding in group 1 was 6.7% of cases, with half of them being the patients with the source from the sternum in the site of wire sutures, while in group 2 4.9% patients underwent resternotomy, with no bleeding from the sites of clip fixation. Thus, the use of nitinol clips after longitudinal median sternotomy is a more reliable method of sternal osteosynthesis (as compared with the classical method), which enables us to minimize the risk of damage to the retrosternal structures, preserve sternal consolidation and reduce blood loss in the drainages in the early postoperative period.

[Twenty Years Experience of the Surgical Treatment of Giant Ascending Aortic Aneurysms]

Giant ascending aortic aneurysm is one of the worst lesions of the cardiovascular system. Timely surgical treatment provides the only chance to prolong the lives of such patients. Life expectancy without surgery in these patients is minimal; they die from a ruptured aneurysm.

[One-stage carotid and coronary artery surgeries in the treatment of multifocal atherosclerosis]

One of the most severe forms of multifocal atherosclerosis often accompanied by heart attacks and strokes is concomitant coronary and carotid artery disease. Unfortunately to date there have been no qualitative randomized trials allowing us to develop a unified optimal approach to the treatment of this pathology. We have analyzed the treatment of 128 patients with coronary artery disease and atherosclerotic carotid stenosis operated on the two vascular territories over the past 10 years in the Department of Surgery of the Aorta and its Branches of the Petrovsky National Research Center of Surgery. One-stage reconstruction in two arterial basins was performed on the majority (75%) of patients. Other patients underwent multistage procedures including the use of endovascular techniques. The absence of any significant differences in mortality and postoperative complications between groups subjected to single- and multi-stage treatment, doubtless reduction of risk of vascular complications in uncorrected arterial bed by one-stage reconstruction allows us to consider this treatment strategy the method of choice in the management of this pathology. Overall surgical mortality of patients with combined coronary and carotid artery involvement subjected to our strategy was 0.8%.

[Twenty Years' Experience of the Surgical Treatment of Giant Ascending Aortic Aneurysms]

Giant ascending aortic aneurysm is one of the worst lesions of the cardiovascular system. Timely surgical treatment provides the only chance to prolong the lives of such patients. Life expectancy without surgery in these patients is minimal; they die from a ruptured aneurysm or decompensation of organs and systems. In this paper, based on two decades' experience of treating patients with giant aneurysms of ascending aorta and aortic arch in B.V. Petrovsky National Research Center of Surgery we have assessed evaluated immediate results of surgery and proposed measures for prevention of possible complications. Out of 53 patients with giant. ascending aortic aneurysms spontaneous rupture after sternotomy or opening of the pericardium occurred in 5 cases. Overall hospital mortality was 1.9%. Our results indicate that with the right tactics surgical repair of giant ascending aortic aneurysms can be performed with a low mortality. Preliminary cardiopulmonary bypass with peripheral cannulation and cooling prior to sternotomy for the possibility of circulatory arrest is a prerequisite of the prevention of fatal massive hemorrhage.

[Surgical treatment for fibro-muscular dysplasia]

AIM

To present the results of surgical treatment of patients with fibro-muscular dysplasia.

MATERIAL AND METHODS

Our experience of treatment of 144 patients with fibro-muscular dysplasia is presented in the article. 118 (82%) patients suffered from stenoses, kinking and aneurysms of internal carotid arteries, 21 (14.5%) patients had lesion of renal arteries, 5 (3.5%) patients--azygous visceral arteries lesion. It was performed 157 reconstructive operations in the Department of cardiac surgery N(o)1 (aortic surgery) of acad. B.V. Petrovskiy Russian Research Center for Surgery for the period from 1993 to 2014. Clinical features of fibro-muscular dysplasia, surgical tactics and technique depending to the localization of lesion are described.

RESULTS

Immediate and remote surgical results were studied. There were no any severe intraoperative and immediate postoperative complications. Follow-up after carotid surgery was 104.49±68.68 months (6-247 months). Strokes were not observed. Hemodynamically insignificant re-stenoses were diagnosed in 7 (5.5%) cases. Mean follow-up after renal reconstructions was 139.24±63.96 months (28-239 months). Persistent blood pressure normalization was achieved in 11 (73.3%) cases. Patients with azygous visceral arteries dysplasia have been examined for the period of 103.4±69.6 months (35-205 months). There were no recurrent aneurysms and abdominal ischemia in the remote postoperative period. Hospital and remote mortality was absent. Based on own experience and colleagues' data we consider that surgical treatment of patients with some forms of fibro-muscular dysplasia provides satisfactory results if advisable strategy is selected.

[Valve-sparing technique for type a aortic dissection with insufficiency of aortic valve]

This article describes clinical experience of surgical treatment of aortic insufficiency in type A aortic dissection using valve-sparing technique. Results of treatment are presented.

[Clinical management of patients with abdominal aortic aneurysms combined with coronary artery disease and multifocal atherosclerosis]

We have analyzed clinical management of 137 patients with atherosclerotic aneurysms of the abdominal aorta combined with coronary artery disease treated during last 10 years in the First Cardiac Surgery Department (Surgery of the Aorta and its Branches) of the Petrovsky National Research Center of Surgery. All patients were subjected to surgery involving both vascular regions: in 130 patients (94.9%) the procedures were staged while 7 patients underwent myocardial revascularization simultaneously with the reconstruction of the abdominal aorta from the minimal access. According to our results staged procedures are safer for patients with atherosclerotic aneurysms of the abdominal aorta combined with coronary artery disease given the organism's limited capacity due to age and comorbidities. Endovascular repair techniques applied both to the coronary arteries and to the abdominal aorta should be always regarded primarily as a gentle form of intervention. In cases where open surgery is required one should try to avoid blood loss, reduce the duration of the procedure and use minimal access surgery when applicable. The overall mortality rate in patients treated for this disorder over the last 10 years was 2.1%.

[Surgical treatment of the aortic dissection type B: analysis of 15 years' experience]

65 patients with the aortic dissection type B were operated on in the period 1995-2010. The proximal local aortic prosthetics proved to be the method of choice in treatment of such patients. The method allowed the reduction of the hospital lethality on 5,7 ± 3,9% and considerably decrease the overall hospital stay.

[Common sense in operative treatment of thoracoabdominal aortic aneurysms]

Treatment approaches of patients with thoracoabdominal aneurysms and aortic dissections type B should be individual. Risk ratio of surgery itself and progression of non-operated disease, such as aneurysm rupture, is the determining factor in defining pro et contra surgical treatment.

[Intima-preserving exoprosthetics of ascending aortic aneurism: 15 years of experience]

Short- and long-term follow-up results of intima-preserving exoprosthetics of ascending aortic aneurism in 50 patients were studied. The group of control consisted of 54 patients, whom traditional linear prosthetics of ascending aortic aneurism had been performed. Time of artificial circulation and myocardial ischemia was significantly shorter in first group: 60,3±2,6 min and 21±1,7min, respectively. Patients of both groups showed no significant aortic distension postoperatively (34,5±0,7 - 36,6±0,8 mm). Thus, a dosed resection of the ascending aortic aneurism with intima-preserving exoprosthetics proved to be relatively simple and promising technique.

[Long-term results of descending and thoracoabdominal aortic aneurisms treatment]

Long-term treatment results of 53 patients operated on thoracoabdominal aortic aneurisms and 7 patients, treated conservatively, were analyzed. Efficacy and choicelessness of operative treatment are demonstrated. 5-year general survival and complication free period for the operated patients were 0.59+/-0.09 and 0,67+/-0,1, correspondingly. 10-year survival and complication free period was 0.51+/-0.1 and 0,34+/-0,14. Unfavourable outcomes are cased by rupture or dissection of non-operated parts of aorta (40%); progressive coronary and carotid arteries occlusion (33,3%); septic complications (13,3%). Possibilities of long-term outcomes improvement after operative treatment of thoracoabdominal aortic aneurisms are proposed.

[Early postoperative complications of surgical treatment of thoracoabdominal aortic aneurisms and dissections]

Early postoperative complications and lethality after 166 operations on the thoracoabdominal aneurisms were analyzed. Overall frequency of the early complications was 31,9+/-3,6%, though some complications could cause the lethality of 88,9+/-10,5%. Thorough evaluation of pre- and intraoperative risk factors and individual patient-defined surgical tactics should lead to the decrease of early complications frequency.

[Staging treatment of aorta aneurysm disease]

Overall 13 patients with aorta aneurysm disease underwent staging operations with 2 weeks - 12 years interval. Surgical treatment of aneurismal lesion of the whole of aorta is very difficult due to severity of the disease and non-typical surgical technique, and characterized by high complications rate and lethality. Individual approach to each patients and staging surgery permitted to achieve the positive results of surgical treatment with 10% lethality.

Primary aortoesophageal fistula: a rare variant of a ruptured chronic posttraumatic dissecting aneurysm of the descending thoracic aorta

Presented herein is own experience in successful management of a female patient diagnosed with a primary aortoesophageal fistula secondary to a rupture of a chronic posttraumatic dissecting aneurysm of the descending thoracic aorta into the oesophagus. The contained herein review of the literature deals with the problems concerning surgical policy of and indications for different variants of reconstructive operations on the aorta and oesophagus.

[Methods to protect the spinal cord and visceral organs in surgery of distal aortic dissections]

The problem of protecting the spinal cord and visceral organs in surgery of distal aortic dissections becomes increasingly important today because of a comparatively high incidence rate of complications. Paraparesis in type 3 dissecting aortic aneurysm (DAA) is noted to occur in ischaemia of the spinal cord lasting more than 56.5+/-12 min and the inclusion into the blood flow of less than two responsible intercostal arteries. Multiple-organ insufficiency in type 3 DAA is observed in ischaemia of the visceral organs lasting more than 36.4+/-6.9 min. While using profound hypothermia and circulatory arrest, fatal haemorrhage appears when the duration of the hypothermic arrest is more than 48+/-13.5 min. The used methods aimed at protecting the spinal cord and visceral organs (perfusion-free technique with cerebrospinal fluid drainage, left artio-femoral bypass, circulation arrest with deep hypothermia), optimization of the scope and technique of the operation, shortened duration of ischaemia, inclusion of the maximum number of the spinal arteries into the blood flow, the use of the system of collection and return of blood make it possible to expect a decreased number of complications.

[Prognostication of neurological complication risk after descending and thoracoabdominal aortic aneurysm repair]

Neurological complications after descending and thoracoabdominal aortic aneurysm (TAAA) correction procedures remain a serious challenge. Their prevention implies proactive approach to manageable risk factors: diagnosis and preoperative correction of latent renal failure [odds ratio (OR)=4.72; p=0.08] and minimization the cross-clamp time (OR=7.0; p=0.03). Extended TAAAs, especially type 1 and 2, (OR=8.5; p=0.03) must be operated only in facilities with sufficient experience in such reconstructions. Prognostic model was suggested to calculate precisely the risk of paraparesis. TAAA correction <<without perfusion>> is accompanied by 1.45-fold higher risk of neurological complications then after procedures that are accomplished under protection.

[Quality of patients life after surgical treatment of dissecting aortic aneurysm type B and aneurysms of descending aorta]

Quality of life at the patients with dissecting aortic aneurysm type B and aneurysms of descending aorta were studied with SF-36 questionnaire before and after surgical treatment. Quality of patients life before and after surgical treatment is lower compared with health population. Reconstructive operation takes beneficial effect on life quality at long-term postoperative period.

Local repair of distal thoracal aortic dissections (Locus minoris resistencia)

The paper presents the method of local repair of distal aortic dissections. Local aortic grafting for surgical correction of type B dissecting aortic aneurysms helped to decrease hospital mortality up to 15.4%, the rate of paraparesis and multiorgan failure - up to 11.5%.

[Simultaneous interventions on the ascending portion, arch of the aorta and cardiac valves in patients with Marfan's syndrome]

Simultaneous surgical interventions on the aorta and valvular system of the heart were performed in four patients presenting with aortic dissections and aneurysms conditioned by Marfan's syndrome. The following reconstructive operations were carried out: 1) prosthetic repair of the aortic valve and the ascending portion of the aorta by means of a valve-containing conduit with replantation of the openings of the coronary arteries into the side of the prosthesis according to the Benthall - De Bono technique, annuloplasty of the tricuspid valve according to the De Vega technique, valvuloplasty of the mitral valve by the Alferi technique; 2) grafting of the aortic valve and the ascending portion of the aorta by means of a valve-containing conduit with replantation of the openings of the coronary arteries according to the Kabrol's technique, plasty of the tricuspid valve by the De Vega technique; 3) prosthetic repair of the aortic arch with distal wedge-like excision of the membrane of the dissection and directing the blood flow along the both channels, plasty of the mitral valve, plasty of the aortic valve and the ascending portion of the aorta with a valve-containing conduit, accompanied by replantation of the openings of the coronary arteries into the side of the graft according to the Benthall - De Bono technique; (4) plasty of the mitral valve with a disk graft through the fibrous ring of the aortic valve, prosthetic repair of the aortic valve and the ascending portion of the aorta with a valve-containing conduit, accompanied by replantation of the openings of the coronary arteries into the side according to the Benthall-De Bono technique.

[Prosthetic reconstruction of the aortic thoracoabdominal portion with replantation of visceral branches into the side of the prosthesis on separate platforms]

The article deals with a clinical case report of a successful surgical treatment of a patient presenting with type III thoracoabdominal aortic aneurysm according to Crawford, using the technique of separate implantation of all the four visceral branches of the aorta into the side of the prosthesis due to impossibility of implanting them on a single platform.

[Comparative characteristic of surgical approaches for aneurysms of thoracoabdominal aorta]

The surgical approaches for aneurysms of thoracoabdominal aorta are analyzed. Both thoracoretroperitoneal and thoracolaparotomic approaches are appropriate; they are up to quality of visualization and manipulation on low-thoracic part, visceral branches and bifurcation of aorta that is verified by experimental studies (wound depth 11-15 cm, angle of surgical action 100-110 degrees, angle of surgical action axis 80-90 degrees). The level of thoracotomy and type of approach depends on variant of lesion and planned reconstruction. Modified thoracophrenopararectal approach (wound depth 11.4+/-0.2 cm, angle of surgical action 97.0+/-3.7 degrees, angle of surgical action axis 88.0+/-2.0 degrees) is optimal for manipulations on aortic isthmus.

[Albumin surgical glue application during surgical grafting of thoracic aorta]

Primary results of albumin surgical glue application during surgical grafting of thoracic aorta are analyzed. It is demonstrated that the glue is an effective method of hemostasis, permits the surgeon to decrease time of surgery, intra- and postoperative hemorrhage.

[Surgical treatment of false post-traumatic aneurysm of the aortic arch with arteriovenous anastomosis]

Traumatic injuries to the thoracic aorta consequent on closed chest traumas present an extremely severe and unfavourable condition as regards natural history. One of the specific disease variants lies in the formation of false post-traumatic aortic aneurysm with an arteriovenous fistula. In the presence of post-traumatic aneurysm of the thoracic aorta with an arteriovenous fistula, the disease course may be complicated by the phenomena of circulatory decompensation. Taking into account certain features of the morphology and pathogenesis of the given disease, surgical interventions require strict adherence to a number of the rules which make it possible to avoid intraoperative aneurysmal rupture. The present paper describes a case of successful surgical treatment of acute false post-traumatic aneurysm of the aortic arch with an arteriovenous fistula under profound hypothermia and circulatory arrest. Presented herein is also a review of the literature concerned with the topic.

Staged surgical treatment of vasorenal hypertension in the long-term period after repair of the thoracoabdominal aorta

Presented herein are a rare clinical case and the results of successful staged surgical treatment of a patient with vasorenal hypertension, who had undergone repair of the thoracoabdominal aorta from the isthmus to the bifurcation with replantation of the intercostal, visceral and renal arteries according to Crawford. In the long-term period, the patient developed bilateral stenosis of two left and then of the right renal arteries. Correction of vasorenal hypertension required a special approach. In view of infeasibility of the use of the aorta for proximal anastomosis establishment (commissural process, deranged wall and graft) staged bypass grafting of two left and right renal arteries was performed.

[Grafting of carotid arteries]

Over 5-years, 167 reconstructive surgeries for stenosis of internal carotid arteries (ICA) were performed in 124 patients. Mean age of the patients was 63.5 years. One hundred and twenty-nine carotid endarterectomies (CEAE) in 86 patients and 38 reconstructive operations of ICA in 38 patients were performed. There were no lethal outcomes in short- and long-term postoperative period. In short-term period after prosthesis of ICA restenosis was revealed in 3% patients, after eversion CEAE in 3% patients the embolism was seen, after standard CEAE restenosis were diagnosed in 8% patients and thrombosis -- in 3%. In long-term period after grafting of ICA the strokes were seen in 3%, stenosis -- in 6% patients, after eversion endarterectomy -- in 0 and 3% patients, and after standard CEAE -- in 3 and 24% patients, respectively. It is concluded that grafting of ICA is adequate surgical method of reconstruction and stroke prevention in specific variants of carotid atherosclerosis.

Surgical policy in the treatment of SAD patients with thoracic and thoracoabdominal aortic aneurysms

The paper reviews an experience gained with the treatment of 30 CAD patients with thoracic and thoracoabdominal aortic aneurysms. They were examined and treated at the Department of Surgery of Aorta and Its Branches, RSCS RAMS from January 1991 to November 2004. All the patients were provided reconstructions for thoracic and thoracoabdominal aortic aneurysms. In 27 of them myocardial revascularization was performed concurrently with aortic reconstruction. When choosing the surgical policy we adhered to the concept of performing one-stage operations via a single access. In most cases, proximal anastomoses were, during surgical treatment of this pathology, constructed "atypically": with the aortic arch, brachiocephalic trunk: and carotid artery, with the descending aorta, and mammaro-coronary bypass grafting was performed. On repair of aneurysms of the distal portion of the arch and descending aorta we accomplished an enlarged left-sided lateral thoracotomy or thoraco-phreno-retro-peritoneal access. It is to be noted that myocardial revascularization was performed twice, using the descending aorta for establishment of proximal anastomosis of coronary bypass. In two cases, revascularization was carried out by means of mammaro-coronary anastomosis. In one case, dual autogenous vein graft and replacement ox the descending aorta was performed from a transverse trans-bipleural access along the fourth intercostal space under extracorporeal circulation. In patients provided one-stage operation on the aorta and coronary-arteries, the main complication was bleeding at operation and in the short-term postoperative period. In staged surgical treatment of CAD patients with thoracic and thoracoabdominal aortic aneurysms, the complications arose from uncorrected coronary pathology, namely iron ischemia and myocardial infarction. Analysis of the results evidences that one-stage surgical treatment of thoracic and thoracoabdominal aortic aneurysm and CAD is an effective method which permits the attainment of beneficial results in 93.6% of patients.

Intraoperative ruptures of thoracic aortic aneurysms

Intraoperative rupture of thoracic aortic aneurysm is a severe complication which may have an adverse effect on the outcome of operation. Among all intraoperative aneurysmal ruptures the most difficult and uncontrolled are ruptures of aortic aneurysms in the presence of dissection and of false aortic aneurysm during repeat interventions in this area. At intraoperative aortic rupture the priority task of the surgical team consists in urgent attainment of maximal temporary hemostasis and an adequate replenishment of blood loss. Presented herein are two most demonstrative clinical cases of intraoperative aortic ruptures: of the ascending aorta during cannulation of the right atrium and of false aneurysm of the aortic isthmus, which developed after aortic isthmoplasty by dacron patch for coarctation where the posterolateral wall of aneurysm was visceral pleura of the left lung. The authors provide a detailed description of the treatment policy for the given condition. Review the reported data pertaining to the problem under consideration.

[Comparative description of approaches in surgical treatment of aneurysms of descending thoracic aorta]

Surgical treatment of patients with thoracic and thoracoabdominal aortic aneurysms is one of the most difficult and topical problems of up-to-date cardio-vascular surgery. Right choice of surgical approach is important condition for effective surgery. This study is dedicated to comparative evaluation and definition of clear indication for choice of surgical approach in reconstruction of thoracic aneurysms. It is concluded that thoracotomy through 3(rd) intercost is preferable in isolated lesion of isthmus and proximal part of descending aorta. Approach through 5(th) intercost is not recommended in this localization of aneurysm. Prosthesis of all descending thoracic aorta (from arch to diaphragm) must be performed through double left-sided thoracotomy with single skin incision (left-sided double thoracotomy through 3(rd) and 6(th) intercosts from single S-type skin incision). This approach always permits to perform surgical reconstruction of distal part of aortic arch, isthmus and all descending aorta, forms optimal conditions for creation of proximal and distal anastomosis.

A comparative study of the aortic wall in patients with Marfan's syndrome and Erdheim's disease

The materiel of intraoperative biopsies (378) and autopsies was used to study the morphology of the aortic wall in patients with Marfan's syndrome (62) and Erdheim's disease (133). Histological, histochemical and electron microscopy research methods were employed with an assay of the results obtained. It has been demonstrated that in connective tissue dysplasia in the aorta, the histological structure of the intima undergoes substantial changes alongside the pathology of the tunica media. It is marked by the formation of a focal and diffuse thickening with the predominance of the interstitial substance, rich in glycosaminoglycans, and of a small amount of fibrous structures. The morphological signs of the impairment of endothelial permeability (vacuolisation of cytoplasm, thinning of its peripheral portions and basal membrane, expansion of intercellular fissures) are identifiabe, which leads to the disorder of aortic wall metabolism and early development of atherosclerosis. The changes in the intima together with the pathology of the tunica media ere predisposing factors of aneurysm formation, dissection and rupture of the aorta.

[Surgical treatment of a patient with carotid and renal artery stenoses]

A case report presents successful surgical treatment of a patient with multifocal atherosclerosis, impaired carotid arterial territory and renovascular hypertension resulted from subtotal renal artery stenosis. Clinical picture of the case is given in detail, as well as diagnostic examination results and surgical treatment plan, Optimal surgical strategy for such lesions is simultaneous surgery of carotid and renal arteries or staged correction beginning with carotid arteries. In the described case the staged intervention was chosen, but it was complicated by iliac arterial thrombosis during the attempt of renal artery angioplasty. From thoracophrenoperitoneal access simultaneous grafting of left renal artery with synthetic prosthesis and recanalization of blood flow in right lower limb were executed.

[Aneurysm of the ascending aorta in its coarctation]

In long-term period after resection of aorta coarctation, 9-14% patients developed aortic aneurysms, one third of them localized in the ascending aorta. From 146 patients operated on for aneurysm of the ascending aorta, 3 had aortic coarctation. In 2 patients aneurysms of the ascending aorta formed late after resection of the coarctation, the third patient was hospitalized with clinical picture of cardiac insufficiency at terminal stage due to coarctation of the aorta and a giant aneurysm of the ascending aorta with significant aortic insufficiency. The patients underwent successful surgeries: 1) ascending aorta grafting; 2) aortic valve and ascending aorta grafting by Bentallo de Bono method; 3) aortic valve and ascending aorta grafting by Bentallo de Bono method with bypass of descending aorta from the conduit. Cystic medianecrosis and two-volume aortic valve were revealed in all the patients. It is concluded that patients after surgery for coarctation of the aorta require long-term follow-up to defect cardiovascular complications early.

Surgical management of patients with ascending aortic aneurysms

Between 1988 and 2002, 104 patients with ascending aortic aneurysms were operated on. The patients were distributed into 2 groups: the first group presented with aortic incompetence (n=66) and the second one had no aortic incompetence (n=38). In the first group, 8 patients received valvesparing operations, 58 (88%) patients underwent replacement of the aortic valve and ascending aortic segment according to different techniques. In the second group, 20 (53%) patients underwent graded aneurysmal resection and intimasparing exoreplacement by synthetic grafts and 18 (47%) were provided supravalvular replacement of the ascending aorta. In the shortterm postoperative period, the lethality in the first group accounted for 3% (6 patients), in the second group, it was equal to 2.6% (1 patient): of note, in the group provided aortoplasty, the lethality was 0%. In ascending aortic aneurysm associated with aortic incompetence, the Bentall DeBono operation is the method of choice of surgical treatment. Valvesparing operations are to be performed according to strict indications (in the absence of anuloaortic ectasia and microscopic lesions of aortic valve cusps). The graded resection of aneurysm with intimasparing exoreplacement may be an alternative to linear replacement of the ascending aorta in ascending aortic aneurysm without aortic incompetence and in the absence of aortic wall dissection.

[Dissection and dissected aneurysm of the abdominal aorta]

Experience in successful treatment of 7 patients with isolated dissection of the abdominal aorta is presented. Over the last 10 years 165 patients with dissected aneurysms of different sites underwent surgery. In 7 (4.2%) of them isolated dissection of the abdominal aorta was diagnosed. Among 251 patients operated for abdominal aortic aneurysm dissection of its wall was seen in 2.8% cases. Morphologic study revealed atherosclerosis in 3 patients, degeneration of aortic wall - in 3, and combination of dysplasia with atherosclerosis - in 1. Linear prosthesis of abdominal aorta with replantation of visceral branches on single area into graft was the main (6) surgery. Bifurcation aorto-iliac prosthesis with bypass of the distal part of the deep femoral artery was performed in 1 patient. Five patients underwent elective surgery, 2 - emergency surgery.

[Surgical treatment of patients with aortic aneurysm and ischemic heart disease]

Experience in the treatment of 153 patients with aortic aneurysms and ischemic heart disease was analyzed. Twenty-five patients with ischemic heart disease underwent reconstructive surgeries for thoracic and thoracoabdominal aneurysms of the aorta. Reconstructive surgeries on the aorta without ones on coronary arteries were performed in 3 of them. In the rest of the 22 patients both myocardium revascularization and aortic reconstruction were performed. Combination of abdominal aorta aneurysms with ischemic heart disease was seen in 128 patients, all of them were operated. Reconstruction of the abdominal aorta without coronary surgery was performed in 109 patients. Myocardium revascularization as the first stage of surgery was performed in 8 patients. Eleven patients underwent simultaneous surgeries on the coronary arteries and abdominal aorta. Technical features of different variants of surgeries were developed and described in detail. It is concluded that simultaneous surgeries on the aorta and coronary arteries permit to achieve good results in patients with aortic aneurysms and ischemic heart disease. Simultaneous grafting of thoracic and thoracoabdominal aorta with coronary arteries bypass leads to positive results in 90.9% cases.

[Surgical treatment of giant aneurysms of ascending parts and arch of the aorta in condition of deep hypothermia and circulatory arrest with artificial assisted circulation]

Sternotomy in giant (10 cm and more in diameter) aneurysms is highly dangerous due to possibility of injury of aneurysmatic wall with fatal bleeding. That is why sternotomy in condition of artificial circulation (AC) and cooling of patients to 29-30 degrees C are preferred. Two cases of successful surgical treatment of critical patients with giant aneurysms of ascending parts and arch of the aorta in condition of femoro-femoral AC, hypothermia (20 degrees C) and circulatory arrest are presented. One of the patients had a giant false posttraumatic aneurysm of an ascending part of the thoracic aorta with fistula between aneurysm and pulmonary artery. Suturing of defects of ascending aorta and pulmonary artery wall, aneurysmorrhaphia of pulmonary artery were performed. The other patient with acute disruption of a giant dissected aortal aneurysm and hemomediastinum underwent prosthesis of ascending part and arch of the aorta.

[Surgical technologies in the treatment of aneurysms of thoracic and thoraco-abdominal aorta]

From 1993 to 2001 279 patients with aneurysms of the thoracic and thoracoabdominal aorta were operated. Cause of aneurysm formation in 74% cases was degenerative changes of aortal wall (Marfan's disease or Erdheim syndrome). Aneurysms were revealed in ascending aorta in 38 (14%) cases, in the ascending aorta with insufficiency of aortic valve--in 67 (24%), in the ascending aorta and aortic arch--31 (11%), in descending aorta--54 (19%), thoracoabdominal aneurysms--in 89 (32%). Twenty patients underwent surgery for combined aneurysms of the ascending aorta with it arch and descending part, thoracoabdominal aneurysms, and also for thoracic aneurysms in combination with coronary heart disease. Lethality in early postoperative period in patients with aneurysms of the ascending aorta was 5%, with aneurysms of the ascending aorta and insufficiency of the aortic valve--6.2%, in aneurysms of the ascending aorta and aortic arch--16.2%, in aneurysms of the descending aorta--6.4%, in thoracoabdominal aneurysms--15%.

[The diagnosis and surgical treatment of post-traumatic aneurysms of the brachiocephalic arteries]

This paper is concerned with the diagnostic technologies and the policy of surgical treatment of patients with traumatic injuries to the carotid arteries, which allowed to avoid fatal events and to attain optimal results in this severe patient group. The authors provide a detailed description of the procedure of spiral computed tomography with contrast examination of the arterial bed as well as of the technical aspects of operation with special reference to two patients.