Surgery of atherosclerotic disease of carotid arteries in patients receiving substitutive therapy for chronic renal failure

Spitalul Mariinski, St.Petersburg, Rusia, Al XII-lea Congres al Asociației Chirurgilor „Nicolae Anestiadi” din Republica Moldova cu participare internațională 23-25 septembrie 2015Introducere: Complicaţiile cardiovasculare sunt cauza principală a mortalității la pacienţii aflaţi sub tratament substitutiv al insuficienţei renale cronice. În acest grup de bolnavi riscul dezvoltării aterosclerozei este foarte înalt – de 10-20 ori mai mare comparativ cu populaţia generală. Aşadar, pacienţii cu insuficienţă renală cronică trebuie să fie consideraţi un grup cu riscul cel mai înalt de complicaţii cardiovasculare ce necesită măsuri profilactice corespunzătoare. Rata dereglărilor neurologice la bolnavii aflaţi la tratament substitutiv al insuficienţei renale cronice oscilează între 40 şi 90% cu o mortalitate ce atinge 80-90% în cazul ictusului. Riscul complicaţiilor chirurgiei arterelor carotide la bolnavii aflaţi la tratament substitutiv este semnificativ mai mare decât la pacienţii fără insuficienţă renală cronică. Factorii principali cu impact negativ asupra prognosticului intervenţiei sunt caracterul generalizat al afecţiunilor aterosclerotice, riscul major al hemoragiilor, controlul dificil al hipertensiuni i arteriale, a dereglărilor metabolice şi electrolitice. Material şi metode: Au fost efectuate 27 reconstrucţii carotidiene la 19 bolnavi ce se aflau sub tratament substitutiv al insuficienţei renale cronice. La 8 bolnavi tratamentul substitutiv a fost realizat prin dializă peritoneală şi la 11 – prin hemodializă. Rezultate: În toate cazurile stenozele hemodinamic semnificative ale arterelor carotide au fost diagnosticate prin CTangiografie sau angiografie digitală. Stenoze asimptomatice ale arterelor carotide au fost diagnosticate la 17 bolnavi, iar 2 pacienţi au suportat în trecut un ictus ischemic. Terapia postoperatorie a fost orientată spre corecţia hipertensiunii, dereglărilor electrolitice şi a coagulopatiei. Complicaţii perioperatorii severe: ictus ischemic sau hemoragic, hemoragie postoperatorie, dereglări dismetabolice sau cardiace – nu au fost înregistrate. Concluzii: Chirurgia leziunilor aterosclerotice ale arterelor carotide la pacienţii cu insuficienţă renală cronică severă reprezintă o problema actuală şi puţin studiată. Reconstrucţiile vasculare pot preveni dezvoltarea complicaţiilor neurologice invalidizante.Introduction: Cardiovascular disorders are the leading cause of mortality among patients receiving substitutive therapy for chronic renal failure. In this subgroup of patients the risk of development of atherosclerosis is especially high – 10-20 times more comparing to general population. Because of this, patients with chronic renal failure should be considered as a cohort with highest risk of cardiovascular complications which requires appropriate prophylactic measures. Rate of neurological disturbances among patients receiving substitutive therapy for chronic renal failure fluctuates from 40 to 90% with mortality achieving 80-90% in case of stroke. The risk of complications in carotid surgery among patients receiving substitutive therapy is significantly higher than in patients without chronic renal failure. The main factors with negative impact upon the prognosis of intervention are generalized character of atherosclerotic lesions, high risk of bleeding, difficult control of arterial hypertension, metabolic and electrolytic disturbances. Material and methods: We performed 27 carotid reconstructions in 19 patients receiving substitutive therapy for chronic renal failure. In 8 patients substitutive therapy was realized by peritoneal dialysis and in 11 patients – by hemodialysis. Results: In all cases the significant flow limiting stenosis of carotid arteries were diagnosed on CT-angiography or digital subtraction angiography. Asymptomatic carotid artery stenosis was diagnosed in 17 patients and 2 patients suffered the ischemic stroke in the past. Postoperative care was centered on correction of hypertension, electrolytic disturbances and coagulopathy. The severe periprocedural complications: hemorrhagic or ischemic strokes, postoperative bleeding, dismetabolic or cardiac disorders were not registered. Conclusions: Surgery of atherosclerotic lesions of carotid arteries in patients with severe chronic renal failure represents the actual and understudied issue. Vascular reconstructions can prevent the development of disabling neurological complications

Morphologically similar but not closely related: the long-spored species of Subulicystidium (Trechisporales, Basidiomycota)

Species boundaries and geographic distribution of corticioid fungi (resupinate Basidiomycota) are often poorly known. Our recent study on Subulicystidium showed that species diversity in this genus is at least twice as high as previously recognized. This re-estimation of the species diversity was based on a study of only a part of the genus. The present study sheds light on molecular and morphological diversity of three more species. We generated 27 ITS and 24 28S nuclear ribosomal DNA sequences from 49 specimens labelled as Subulicystidium cochleum, S. longisporum and S. perlongisporum and collected in distant geographic localities. We assessed pairwise dissimilarities and phylogenetic relationships of DNA sequences with Bayesian and maximum likelihood methods. We correlated phylogenetic information with morphological data on spores and cystidia. We found that the three species are not closely related, despite their similarity in spore shape and size. In one of the species, S. perlongisporum, we detected the presence of two sympatric lineages. These lineages are not morphologically distinct, except for a small difference in the mean length of cystidia. Our study provides a further example of transoceanic species distribution in Agaricomycetes

Effect of dexamethasone therapy on factors of adhesiveness and coagulation in acute lower limb ischemia

Leukocyte-platelet adhesion during hypoxia, tissue damage, activation of inflammation and coagulation is associated with the expression of ICAM-1 membrane molecules and integrins by blood and tissue cells. At the same time, platelet adhesion receptors determine their adhesion to the endothelium and recruited lymphocytes. The role of platelets in the pathogenesis of ischemic cardiovascular diseases also consists in their ability to modulate both hemostasis and inflammatory reactions, which is accompanied by the secretion of inflammatory mediators and factors that promote the recruitment of leukocytes to tissue damage sites. Purpose of the study: to study the effect of the synthetic glucocorticoid dexamethasone on the expression of adhesion receptors CD18+ and CD54+ on leukocytes, the content of platelets and fibrinogen in the blood of patients with ALLI, the relationship of these indicators with the severity and outcome of the disease.To study the effect of anti-inflammatory therapy, a group of 32 patients treated with dexamethasone was formed; the comparison group was represented by 71 patients with basic therapy, the control group consisted of 15 volunteers. After revascularization, all patients received antiplatelet and anticoagulant therapy. Dexamethasone infusions were carried out in a course of 4 to 6 days after reconstructive surgery. In all patients, the content of C-reactive protein in the blood, the content of platelets and fibrinogen were determined. The number of lymphocytes expressing adhesion molecules ICAM-1 (CD54+) and integrins (CD18+) was counted using the immunocytochemical method. Studies were performed before surgery and on days 1, 3, 7, and 10 after surgery.With exacerbation of ischemia and damage to the endothelium, the accumulation of cytolysis products, the expression of adhesion molecules increases both on endotheliocytes and on inflammatory effector cells – leukocytes and platelets. Adhesion molecules conduct an activation signal inside the cell, which promotes adhesion of leukocytes and platelets to the endothelium, lymphocytic-platelet adhesion, the formation of a parietal thrombus, and possible occlusion of damaged vessels. Increased expression of adhesion molecules is associated with the activation of metabolism, inflammation, coagulation and oxidative stress, stimulates all hematopoietic lineages, including platelets. The level of involvement of cellular reactions in the pathogenesis of the disease affects the effectiveness and duration of treatment, the risk of recurrent thrombosis and death. Anti-inflammatory therapy with dexamethasone contributed to earlier remission, a decrease in the proportion of infectious complications, such as wound suppuration from 10% to 6%, the number of necessary amputations from 32% to 16%, the frequency of deaths from 31% to 6%, and a reduction in hospital stay from 13 days to 10.Inflammation, adhesiveness of effector cells and thrombosis are important factors in the pathogenesis of acute lower limb ischemia. Therapy with dexamethasone helps to reduce the level of systemic inflammatory response, the number of necessary amputations, the number of complications and adverse outcomes in the treatment of ALLI, and reduce the length of stay in the hospital

Optimum technique of carotid artery reconstruction in her atherosclerotic lesion

Purpose of the study. Was to compare the early and long-term results of different variants of the classical KEAE.Materials and methods. In a retrospective study, we collected data on 1.242 patients who trans- ferred KEA from January 2011 to December 2019, using a patch was performed in 239 cases in 1003 — primary suture closure. We used 3 methods of arteriotomy closure with the use of a patch. There were 848 men and 394 women, the average age was 63.16 years, all of them were sympto- matic. Most patients had a transient disorder (49.2%) or ischemic stroke (50.8%). All patients had significant (moderate to severe) carotid stenosis. After the operation 5 (0.4%) patients had ischemic stroke, 1 (0.08%) had n. hypo-glossus damage, 3 (0.24%) had postoperative hematoma. The usual endarterectomy was performed without a shunt in all cases. All arteriotomies were mostly open. Early and late results of this procedure with a period of observation of at least 36 months were ana-lyzed: technical aspects of arteriotomy, features of restoration of the integrity of the vessel, changes in the "geometry" of the vessel, the use of zaplat. We studied the state of hemodynamics and complications in the early (30 days) and late postoperative period, the development of restenosis was compared between groups during the 36 months of observation. Results. When assessing the geometrical changes in the group with the patching, it was noted that the worst results were obtained using the technique with a U-shaped fixation suture on the distal part of the patch and the use of a wide patch. When using a narrow patch geometric changes in the width of the patch are the smallest. The main reason of the frequent geometrical changes in the dis-tal part of the patch was the patch wrapping inside the artery with the formation of a duplicate. The application of the modified technique of patch closure allowed to reduce the number of distortions in the operation area, to avoid the formation of artery stenoses in the place of patch imposition, to prevent changes in the bifurcation geometry of the internal carotid artery. The best results in the application of the primary edge suture were obtained by the method of closing the arteriotomy with the counter edge suture with the precision control of the application. The application of the U-shaped suture along the edges of the arteriotomy allowed avoiding deformations in this place. Con-trol of needle injection by means of straightening and lifting of the wall edge ensured absence of deformations in the suture.Conclusions. The post-CEAE closure technique affects the hemodynamic profile. Sewing patch-ing does not seem to create favorable flow dynamics. Consideration should be given to the elective use of the patch to improve disturbed flows. However, the linear precision suture remains the method of choice for suturing the arteriotomy

EXTRACRANIAL NON-ATHEROSCLEROTIC PATHOLOGY OF THE CAROTID ARTERY IN THE CAUSES OF ACUTE ISCHEMIC STROKE

Purpose. We present the experience of treatment of patients with cerebral vascular accident by the ischemic type, the cause of which was non-atherosclerotic lesion of brachiocephalic arteries.Materials and methods. During 2011–2015 years 4118 patients with acute ischemic stroke were observed. Of these, 589 patients (14.3%) were operated in the acute period of stroke in the period from 4–6 hours to 14 days. The cause of the stroke was various types of pathology of the extracranial divisions of the brachiocephalic arteries (EDBA). Of this number, with atherosclerotic carotid artery stenoses, 336 patients (57.1%) were operated on, with non-atherosclerotic pathology of carotid arteries — 253 patients (42.9%). Of these 253 patients, dissection of the intima of the carotid arteries was detected in 10 (3.9%) patients, aneurysms in the extracranial segment of the ECA and ICA were detected in 14 (5.5%), and 229 (90.6%) revealed various types of tortuosity and kinks carotid arteries and fibrous dysplasia. All patients are operated on. Various types of reconstructions of carotid arteries with a good clinical effect have been performed. There were no lethal outcomes.Concusions. The data obtained in the study confirm the opinion that not only atherosclerotic lesions of the ICA are an indication for surgical treatment at an early date. This stage is an important part of the comprehensive rehabilitation of patients with acute ischemic stroke

Morphological and molecular diversity of the Phanerochaete sordida complex (Polyporales, Basidiomycota) in temperate Eurasia

Based on a morphological study of more than 70 herbarium specimens (AR, CWU, H, INEP, LE, OHHI, S, TAA, VLA) from temperate Eurasia, the differences (shape and size of basidiospores and hymenial cells, as well as cystidia) between two groups within the Phanerochaete sordida species complex have been revealed. The phylogenetic analysis of ITS sequences shows the presence of the 5 monophyletic lineages with high support values what correlates with morphological, ecological (host preferences) and geographic patterns