Long-term outcomes of a novel method of femoropopliteal bypass

Aim. To analyze the long-term outcomes of a novel method of femoropopliteal bypass (FPB) surgery.Material and methods. This retrospective, open-label, comparative study for the period from October 1, 2016 to December 25, 2019 at the Research Institute of the S. V. Ochapovsky Regional Clinical Hospital №1 (Krasnodar Krai) included 473 patient who underwent FBP. Depending on the type of graft, 5 groups were formed: group 1 (n=266) — reversed vein (great saphenous vein (GSV)); group 2 (n=59) — autologous vein graft (GSV) prepared in situ; group 3 (n=66) — autologous vein graft (GSV) prepared ex situ; group 4 (n=9) — synthetic graft (Jotec, Germany); group 5 (n=73) — upper limb veins. In all cases, Multislice computed tomography angiography revealed an extended (25 cm or more) Trans-Atlantic Inter-Society Consensus (TASC II) class D occlusion of the superficial femoral artery. The longterm follow-up period was 16,6±10,3 months. The technical result of novel FPB technique was achieved using proposed type of an autologous vein graft preparation, in which, after GSV isolation, ex situ valvulotomy was performed, followed by the non-reversed subfascial orthotopic graft passage along the neurovascular bundle by tunneling (Sheath Tunneler Set; Peripheral Vascular, USA) soft tissues. The GSV ex situ was prepared as follows: the GSV was isolated from the saphenofemoral fistula in the distal direction to the required length and removed from the wound. Further, valvulotomy was performed through the proximal end of GSV. Then the valvulotome was removed and a metal cannula was inserted. Through it, a saline solution at indoor temperature with unfractionated heparin was injected into the GSV lumen, simulating blood flow, and the quality of the performed valvulotomy was assessed.Results. In the inhospital postoperative period, all complications developed in groups 1, 2, 3 and 5. However, no significant intergroup statistical differences were found. In the long-term follow-up, there were no significant intergroup differences in the prevalence of deaths (group 1: 4,6%; group 2: 1,7%; group 3: 4,6%; group 4: 0%; group 5: 2,8%; p=0,78), myocardial infarction (group 1: 1,9%; group 2: 0%; group 3: 1,5%; group 4: 0%; group 5: 0%; p=0,62), ischemic stroke (group 1: 0,8%; group 2: 1,7%; group 3: 1,5%; group 4: 0%; group 5: 0%; p=0,8) and shunt thrombosis (group 1: 14,5%; group 2: 19,3%; group 3: 18,5%; group 4: 44,4%; group 5: 19,7%; p=0,16). However, the highest number of limb amputations (group 1: 4,2%; group 2: 5,3%; group 3: 9,2%; group 4: 22,2%; group 5: 1,4%; p=0,03) and the highest rate of composite endpoint (sum of all complications) (group 1: 26,0%; group 2: 28,1%; group 3: 35,4%; group 4: 66,7%; group 5: 23 ,9%; p=0,05) were observed in patients with synthetic prosthesis.Conclusion. FPB with the autologous vein graft ex situ is characterized by a comparable inhospital and long-term outcomes with BPS using the reversed autologous vein and autologous vein in situ. Thus, this surgical technique may become one of the preferable operations for patients with extended occlusion of the superficial femoral artery

Прогнозирование развития тромбоза бедренноподколенного шунта в отдаленном периоде наблюдения

Aim of study. The development of a program for predicting thrombosis with subsequent amputation of a limb in the long-term period after femoral-popliteal bypass (FPB).Material and methods. This is a retrospective open comparative study performed from January 10, 2016 to December 25, 2019 at Research Institute – Professor S.V. Ochapovsky Regional Clinical Hospital No. 1 of the Ministry of Health of the Krasnodar Territory, Krasnodar, which included 473 patients who underwent FPB. Depending on the type of bypass, five groups were formed: Group 1 (n=266), reversed vein (great saphenous vein (GSV); Group 2 (n=59), autovenous vein (GSV), prepared in situ; Group 3 (n=66), autovenous vein (GSV), prepared ex situ; Group 4 (n=9) synthetic graft (Jotec, Germany); Group 5 (n=73), veins of the upper limb (forearm and shoulder). In all cases of observation, multislice computed tomography with angiography revealed an extensive (25 cm or more) atherosclerotic occlusive lesion of the superficial femoral artery, corresponding to type D according to the transatlantic consensus (TASC II). The long-term followup period was 16.6±10.3 months.Results. During the hospital postoperative period, all complications developed in groups 1, 2, 3 and 5. However, no significant intergroup statistical differences were found. In the long-term follow-up period, according to the mortality rate (group 1: 4.6%; group 2: 1.7%; group 3: 4.6%; group 4: 0%; group 5: 2.8%; p=0.78), myocardial infarction (group 1: 1.9%; group 2: 0%; group 3: 1.5%; group 4: 0%; group 5: 0%; p=0.62), ischemic stroke (group 1: 0.8%; group 2: 1.7%; group 3: 1.5%; group 4: 0%; group 5: 0%; p=0.8) and bybass thrombosis (group 1: 14.5%; group 2: 19.3%; group 3: 18.5%; group 4: 44.4%; group 5: 19.7%; p=0.16), no significant intergroup differences were identified. However, the largest number of limb amputations (group 1: 4.2%; group 2: 5.3%; group 3: 9.2%; group 4: 22.2%; group 5: 1.4%; p=0.03) and the maximum composite endpoint (sum of all complications) (group 1: 26.0%; group 2: 28.1%; group 3: 35.4%; group 4: 66.7%; group 5: 23 .9%; p=0.05) were observed after the use of a synthetic graft. Using “random forest” analysis, a model and computer program was created that allows, the risk (low, medium, high) of developing bypass thrombosis to be assessed interactively, based on clinical, anamnestic, demographic and perioperative data, with subsequent amputation after FPB in the long-term follow-up period.Conclusions. Revascularization strategy for patients with extended atherosclerotic lesions of the femoropopliteal segment should be determined individually and only by a multidisciplinary council. The conduit of choice for femoral-popliteal bypass surgery is an autovenous graft. Synthetic prostheses can only be used in the absence of the latter. To identify a group of patients with a high risk of thrombosis of the femoral-popliteal bypass and limb amputation in the long-term follow-up period, the created risk stratification program for the development of these complications can be used. Precision supervision of these patients in the postoperative period will make it possible to prevent these adverse events in time.Цель. Разработка программы прогнозирования тромбоза шунта с последующей ампутацией конечности в отдаленном периоде после бедренно-подколенного шунтирования (БПШ).Материал и методы. В настоящее ретроспективное открытое сравнительное исследование за период с 10.01.2016 по 25.12.2019 год в ГБУЗ «Научно-исследовательский институт – Краевая клиническая больница № 1 им. профессора С.В. Очаповского» Министерства здравоохранения Краснодарского края, Краснодар были включены 473 пациента, которым выполняли БПШ. В зависимости от вида шунта сформировано пять групп: 1-я группа (n=266) — реверсированная вена (большая подкожная вена (БПВ)); 2-я группа (n=59) — аутовена (БПВ), подготовленная “in situ”; 3-я группа (n=66) — аутовена (БПВ), подготовленная “ex situ”; 4-я группа (n=9) — синтетический протез (Jotec, Германия); 5-я группа (n=73) — вены верхней конечности (предплечье и плечо). Во всех наблюдениях по данным мультиспиральной компьютерной томографии с ангиографией было выявлено протяженное (25 см и более) атеросклеротическое окклюзионное поражение поверхностной бедренной артерии, соответствующее типу D согласно трансатлантическому консенсусу (TASC II). Отдаленный период наблюдения составил 16,6±10,3 месяца.Результаты. В госпитальном послеоперационном периоде все осложнения развились в 1-й, 2-й, 3-й и 5-й группах. Тем не менее, значимых межгрупповых статистических различий выявлено не было. В отдаленном периоде наблюдения по частоте смертельного исхода (группа 1: 4,6%; группа 2: 1,7%; группа 3: 4,6%; группа 4: 0%; группа 5: 2,8%; р=0,78), инфаркта миокарда (группа 1: 1,9%; группа 2: 0%; группа 3: 1,5%; группа 4: 0%; группа 5: 0%; р=0,62), ишемического инсульта (группа 1: 0,8%; группа 2: 1,7%; группа 3: 1,5%; группа 4: 0%; группа 5: 0%; р=0,8) и тромбоза шунта (группа 1: 14,5%; группа 2: 19,3%; группа 3: 18,5%; группа 4: 44,4%; группа 5: 19,7%; р=0,16) значимых межгрупповых различий не выявлено. Однако наибольшее число ампутаций конечности (группа 1: 4,2%; группа 2: 5,3%; группа 3: 9,2%; группа 4: 22,2%; группа 5: 1,4%; р=0,03) и максимальный показатель комбинированной конечной точки (сумма всех осложнений) (группа 1: 26,0%; группа 2: 28,1%; группа 3: 35,4%; группа 4: 66,7%; группа 5: 23,9%; р=0,05) наблюдались после применения синтетического протеза. С применением анализа «случайного леса» была создана модель и компьютерная программа, позволяющая в интерактивном режиме на основе клинико-анамнестических, демографических и периоперацинных данных оценить риск (низкий, средний, высокий) развития тромбоза шунта с последующей ампутацией после БПШ в отдаленном периоде наблюдения.Заключение. Стратегия реваскуляризации пациентов с протяженным атеросклеротическим поражением бедренно-подколенного сегмента должна определяться персонифицированно и только мультидисциплинарным консилиумом. Кондуитом выбора для бедренно-подколенного шунтирования является аутовенозный трансплантат. Синтетические протезы могут применяться только в отсутствии последнего. Для идентификации когорты больных с высоким риском тромбоза бедренноподколенного шунта и ампутации конечности в отдаленном периоде наблюдения может применяться созданная программа стратификации риска развития данных осложнений. Прецизионная курация этих пациентов в послеоперационном периоде позволит вовремя предотвращать перечисленные неблагоприятные события

Long-term outcomes of combined coronary bypass surgery and carotid endarterectomy in patients with type 2 diabetes

At present, there are no studies on the analysis of the incidence of complications in patients with concomitant lesions of the coronary and internal carotid arteries (ICA) after combined operation of carotid endarterectomy (CE) and coronary artery bypass grafting (CABG) against the background of type 2 diabetes (T2D). However, there is no doubt that this condition can be a predictor of cardiovascular and wound complications during in-hospital and long-term postoperative periods.Aim. To study in-hospital and long-term outcomes of combined CABG+CE in patients with and without type 2 diabetes.Material and methods. This multicenter retrospective study for the period from January 2015 to December 2019 included 653 patients with concomitant atherosclerotic lesions of ICA and coronary arteries, who underwent combined CE+CABG. Depending on presence of type 2 diabetes, 2 groups were formed: group 1 (n=183) — patients with type 2 diabetes; group 2 (n=471) — patients without type 2 diabetes. The duration of postoperative follow-up was 37,8±14,9 months.Results. During hospitalization, significant differences in the incidence of death (group 1 =1,1%; group 2 =1,0%; p=0,97), myocardial infarction (MI) (group 1 =1,1%; group 2 =0,8%; p=0,76), bleeding events (group 1 =1,1%; group 2 =0,8%; p=0,76) were not detected. However, stroke (group 1 =3,8%; group 2 =0,4%; p=0,0008), sternal wound infection and mediastinitis (group 1 =3,3%; group 2 =0,2%; p=0,0006) were significantly more often developed in patients with type 2 diabetes.In the long-term follow-up period, death (group 1 =6,6%; group 2 =1,1%; p<0,0001), MI (group 1 =4,9%; group 2 =0,8%; p=0,0008), stroke (group 1 =7,7%; group 2 =1,5%; p<0,0001), ICA restenosis (group 1 =8,8%; group 2 =1,6%; p<0,0001), repeated emergency myocardial revascularization (group 1 =7,2%; group 2 =1,5%; p=0,0002), repeated emergency cerebral revascularization (group 1 =8,8%; group 2 =1,6%; p<0,0001) were significantly more often recorded in patients with type 2 diabetes.Kaplan-Meier curve analysis and its comparison using the log rank test revealed that the death, MI, and stroke were also significantly more often observed in patients with type 2 diabetes (p=0,0007, p=0,003, p<0,0001, respectively).Conclusion. Patients with type 2 diabetes who are referred for combined CE+CABG are at an increased risk of stroke, sternal wound infection and mediastinitis in the in-hospital postoperative period, as well as all adverse cardiovascular events in the long-term follow-up period

Ten-year long-term outcomes of conventional and eversion carotid endarterectomy. Multicenter study

Aim. To analyze the immediate and long-term outcomes of eversion and conventional carotid endarterectomy (CE) with patch angioplasty.Material and methods. For the period from February 1, 2006 to September 1, 2021, the present retrospective multicenter open comparative study included 25106 patients who underwent CE. Depending on the technique of operation, the following groups were formed: group 1 (n=18362) — eversion CE; group 2 (n=6744) — conventional CE with patch angioplasty. The long-term follow-up period was 124,7±53,8 months.Results. In the hospital postoperative period, the groups were comparable in incidence of all complications: lethal outcome (group 1: 0,19%, n=36; group 2: 0,17%, n=12; p=0,89; odds ratio (OR) =1,1; 95% confidence interval (CI) =0,57- 2,11); myocardial infarction (MI) (group 1: 0,15%, n=28; group 2: 0,13%, n=9; p=0,87; OR=1,14; 95% CI=0,53-2,42); stroke (group 1: 0,33%, n=62; group 2: 0,4%, n=27; p=0,53; OR=0,84; 95% CI=0,53-1,32); bleeding with hematoma formation (group 1: 0,39%, n=73; group 2: 0,41%, n=28; p=0,93; OR=0,95; 95% CI=0,61-1,48); internal carotid artery (ICA) thrombosis (group 1: 0,05%, n=11; group 2: 0,07%, n=5, p=0,9; OR=0,8; 95% CI=0,28-2,32). In the long-term follow-up, the groups were comparable only in MI incidence: group 1: 0,56%, n=103; group 2: 0,66%, n=45; p=0,37; OR=0,84; 95% CI=0,59-1,19. All other complications were more frequent after conventional CE with patch angioplasty: all-cause death (group 1: 2,7%, n=492; group 2: 9,1%, n=616; p<0,0001; OR=0,27; 95% CI=0,24-0,3); lethal ischemic stroke (group 1: 1,0%, n=180; group 2: 5,5%, n=371; p<0,0001; OR=0,17; 95% CI=0,14-0,21); non-lethal ischemic stroke (group 1: 0,62%, n=114; group 2: 7,0%, n=472; p<0,0001; OR=0,08; 95% CI=0,06-0,1); ICA restenosis >60%, requiring re-revascularization (group 1: 1,6%, n=296; group 2: 12,6%, n=851; p<0,0001; OR=0,11; 95% CI=0,09-0,12). Thus, the composite endpoint (lethal ischemic stroke + non-lethal ischemic stroke + MI) after conventional CE with patch angioplasty was more than 6 times higher than this parameter of eversion CE: group 1: 2,2%, n=397; group 2: 13,2%, n=888; p<0,0001; OR=0,14; 95% CI=0,12-1,16.Conclusion. Conventional CE with patch angioplasty is not prefer for cerebral revascularization in the presence of hemodynamically significant ICA stenosis due to the high prevalence of deaths, stroke, and ICA restenosis in the long-term follow-up

CarotidSCORE.RU — risk stratification for complications after carotid endarterectomy

Aim. To demonstrate the first Russian computer program (carotidscore.ru) for risk stratification of postoperative complications of carotid endarterectomy (CE).Material and methods. The present study is based on the analysis of a multicenter Russian database including 25812 patients after CE operated on from January 1, 2010 to April 1, 2022. The following types of CE were implemented: conventional CE with patch angioplasty — 6814 patients; eversion CE — 18998 patients. Following postoperative complications were assessed during the study: death, stroke, myocardial infarction (MI), composite endpoint (death + stroke + MI).Results. During inhospital postoperative period, 0,18% of participants died, while 0,14% had MI, 0,35% — stroke. The composite endpoint was recorded in 0,68%. For each factor present in patients, a predictive coefficient was estimated. The predictive coefficient was considered as a numerical parameter reflecting the strength of the effect of each factor on the development of postoperative complications. Based on this equation, predictive coefficients were calculated for each factor present in patients in our study. The total contribution of these factors was reflected as a percentage and denoted the risk of postoperative complications with a minimum of 0% and a maximum of 100%. On the basis of obtained calculations, a CarotidSCORE program was created. Its graphical interface is based on the QT framework. It is possible not only to estimate the risk of a complication, but also to save all data about a patient in JSON format. The CarotidSCORE program contains 47 patient parameters, including clinical, demographic, anamnestic and angiographic characteristics. It makes it possible to choose one of the four CE types, which will provide an accurate stratification of the complication risk for each of them.Conclusion. CarotidSCORE (carotidscore.ru) may determine the probability of postoperative complications in patients undergoing CE

CLINICAL CASE OF SURGERY FOR FALSE ANEURYSM OF THE INTERNAL CAROTID ARTERY AFTER CAROTID ENDARTERECTOMY AND CAROTID ANGIOPLASTY

In this article a clinical case of surgical treatment for false aneurysm of extracranial department of an internal carotid artery in a 69-year-old patient after numerous surgical treatment for stenosis atherosclerosis of an internal carotid is described. The diagnostic algorithm consisted of triplex scanning of brachiocephalic arteries, a cerebral angiography and a multispiral computer tomography with intravenous contrast enhancement. This patient underwent carotid endarterectomy in combination with reconstruction of an internal carotid and removal of earlier implanted stent and a synthetic patch were performed. The postoperative period was uneventful. Histological assessment proved that extension of an internal carotid was caused by a false aneurysm. Previous surgery and atherosclerosis were the reasons of aneurysm formation