Эндоваскулярное лечение острого тромбоза тибиоперонеального ствола. Клинический случай

Introduction. Acute limb ischemia is a severe disorder caused by a sharp drop in the arterial perfusion of the limb. It carries a threat to the limb’s function and viability. The issue of early recognition of acute limb ischemia in surgery is both important and difficult. The current guidelines recommend that patients with acute limb ischemia when the limb is viable should be urgently examined and treated. Restoring the blood flow in patients with acute limb ischemia is a priority, since a significant reduction in arterial perfusion can lead to limb amputation and life-threatening complications. In acute limb ischemia different treatment methods can be used, both open surgery and endovascular procedures. The treatment strategy depends on the localisation, duration of ischemia, neurological deficit, concomitant diseases and risks associated with treatment and its results. Endovascular procedures on the arteries of the lower leg are most often indicated to save a limb. Endovascular procedures on the arteries of the lower leg are indicated more often in patients with critical limb ischemia. Endovascular procedures when the condition is primary demonstrate good outcomes and high efficiency on the arteries of the lower extremities at all levels of the lesion.Materials and methods. This paper presents a clinical case of a successful endovascular procedure performed for the treatment of acute thrombosis of the arteries of the lower leg. Three stents were implanted, with a good angiographically confirmed outcome.Conclusion. Endovascular balloon angioplasty with stenting of the tibioperoneal trunk can result in good outcomes in patients with acute thrombosis of the arteries of the lower leg.Введение. Острая ишемия конечности (ОИК) — тяжелое заболевание, в основе которого лежит резкое уменьшение артериальной перфузии конечности, создающее потенциальную угрозу ее функциональности и жизнеспособности. Проблема своевременного распознавания острой ишемии конечности является одновременно важной и сложной в хирургии. Согласно современным рекомендациям, пациенты с острой ишемией конечности и сохраненной ее жизнеспособностью должны быть экстренно обследованы и пролечены. Восстановление кровотока при ОИК является приоритетной задачей, так как значительное снижение артериальной перфузии может привести к ампутации конечности и угрожающим жизни осложнениям. При острой ишемии конечности могут применяться разные методы лечения — как открытая хирургия, так и эндоваскулярная операция. Тактика лечения будет определяться на основании локализации, продолжительности ишемии, неврологического дефицита, сопутствующих заболеваний и связанных с лечением рисков и его результатов. Эндоваскулярные операции на артериях голени чаще всего показаны для спасения конечности. Увеличивается количество рекомендаций в пользу эндоваскулярной операции на артериях голени у больных с критической ишемией конечности. Эндоваскулярные операции при первичном заболевании показывают хороший результат и высокую эффективность на артериях нижних конечностей на всех уровнях поражения.Материалы и методы. В статье представлен клинический случай успешного эндоваскулярного лечения острого тромбоза артерий голени. В ходе оперативного лечения были имплантированы три стента с хорошим ангиографическим результатом.Заключение. Эндоваскулярная баллонная ангиопластика со стентированием тибиоперонеального ствола может успешно применяться в случае развития острого тромбоза артерий нижних конечностей

Осложнение в ходе эндоваскулярного вмешательства: острая ишемия нижней конечности в результате спиралевидной диссекции при антеградной пункции левой общей бедренной артерии

Introduction. Over the past decade, endovascular interventions have become widely used in patients with obliterating atherosclerosis of lower extremity arteries. This is due to the low-trauma nature of the methodology, various technological achievements in the improvement of instruments and the accumulation of operational experience. However, despite all the successes achieved, no intervention is without its complications. In the case of endovascular interventions, complications are most commonly associated with the site of arterial access. One of the most widely-used arterial approaches is retrograde femoral access. However, if an intervention is planned on the femoropopliteal arterial segment, the antegrade femoral approach is generally the method of choice. Among the advantages of antegrade access can be noted the shorter path to the site, better toolkit support and a shorter operation duration. One of the main complications involved in antegrade access is the development of dissection. Although this complication occurs in less than 1% of cases, it carries a threat of critical ischemia of the lower limbs, which may require emergency open surgery up to and including emergency limb amputation.Materials and methods. The paper presents a clinical case of successful treatment of iatrogenic spiral dissection, which occurred following antegrade vascular access. During surgical treatment of this complication, stents were implanted throughout the dissection to “press” the exfoliated layer of the intima.Results. The study presents a case of iatrogenic spiral dissection after antegrade femoral puncture followed by successful endovascular treatment of this complication.Conclusion. Endovascular balloon angioplasty and stenting can be successfully used when iatrogenic dissection develops following antegrade puncture of the right femoral artery, allowing classic “open” surgical intervention to be avoided.Введение. За последнее десятилетие эндоваскулярные вмешательства стали широко применяться у пациентов с облитерирующим атеросклерозом артерий нижних конечностей. Этому способствовали малая травматичность методики, достижения науки и техники в усовершенствовании инструментария и накопление опыта операторов. Несмотря на все достигнутые успехи, у любого вмешательства есть свои осложнения. При эндоваскулярных вмешательствах наиболее часто осложнения связаны с местом артериального доступа. Одним из распространенных артериальных доступов служит ретроградный бедренный доступ. Однако если планируется вмешательство на бедренно-подколенном артериальном сегменте, методом выбора служит антеградный бедренный доступ. Из преимуществ антеградного доступа можно отметить более короткий путь до поражения, лучшую поддержку инструментария и сокращение длительности операции. Одним из осложнений антеградного доступа является развитие диссекции. Данное осложнение возникает менее чем в 1 % случаев, но таит в себе угрозу критической ишемии нижней конечности, что может потребовать экстренной открытой операции, вплоть до экстренной ампутации конечности.Материалы и методы. В данной работе представлен клинический случай успешного лечения ятрогенной спиралевидной диссекции, возникшей после антеградного сосудистого доступа. В ходе оперативного лечения данного осложнения последовательно были имплантированы стенты на всем протяжении диссекции, чтобы «прижать» отслоившийся слой интимы.Результаты. В работе показан случай ятрогенной спиралевидной диссекции после антеградной бедренной пункции с последующим успешным эндоваскулярным лечением данного осложнения.Заключение. Эндоваскулярная баллонная ангиопластика и стентирование могут успешно применяться в случае развития ятрогенной диссекции после антеградной пункции правой бедренной артерии и помочь избежать классического «открытого» оперативного вмешательства

Эндоваскулярное лечение стеноза почечной артерии, вызванного фибромускулярной дисплазией. Клинический случай

Introduction. Fibromuscular dysplasia (FMD) is an idiopathic, non-atherosclerotic, non-inflammatory disease of arteries. Careful research into this disorder showed that FMD has been found in every arterial bed in the body; the most common arteries affected are renal arteries and extracranial sections of carotid and vertebral arteries. The clinical presentation is determined by the localization of the vasculature affected and the stenosis severity. Today FMD is a very rare disease with the incidence of 4 per 1000 people. The diagnosis today is difficult and may take a long time. According to the latest European Society of Cardiology guidelines renal artery balloon angioplasty is indicated for patients with FMD; if a good angiographic result is achieved (no dissection, TIMI 3 flow) no renal artery stenting required. The treatment success depends on the early diagnosis.Materials and Methods. This paper presents a clinical case of renal artery stenosis caused by fibromuscular dysplasia that was treated successfully with balloon angioplasty without stenting.Results and discussion. Protracted process of diagnosing this disease may result in deteriorating quality of life and poor outcomes such as difficult-to-control hypertension and its sequelae, TIA, stroke, aneurism dissection or rupture. It is worth pointing out that FMD diagnosis may be incidental when imaging is performed for other reasons, or when there is a systolic murmur at arteries in an asymptomatic patient who does not have classic atherosclerosis risk factors. According to the latest guidelines endovascular treatment is indicated for patients with FMD to manage the hypertension; this has proven very effective in improving quality of life.Введение. Фибромускулярная дисплазия (ФМД) — идиопатическое, не атеросклеротическое, не воспалительное поражение артерий. Тщательное изучение данной патологии показало, что при ФМД поражаются все сосудистые русла, наиболее чаще встречаемые — это почечные артерии и экстракраниальные отделы сонных и позвоночных артерий. Клиническая картина ФМД определяется локализацией пораженного сосудистого бассейна и  тяжестью стеноза. На сегодняшний день ФМД является весьма редким заболеванием. Его распространенность примерно 4 на 1000 человек. Своевременная диагностика затруднена, и диагностический поиск может занять много времени. Согласно последним рекомендациям Европейской ассоциации кардиологов пациентам с ФМД показана баллонная ангиопластика почечной артерии, при хорошем ангиографическом результате (отсутствие диссекции, кровоток TIMI 3) без имплантации стента в почечную артерию. Успех лечения зависит от ранней диагностики заболевания. Материалы и методы. В статье представлен клинический случай успешного эндоваскулярного лечения стеноза почечной артерии, вызванного фибромускулярной дисплазией, при помощи баллонной ангиопластики без стентирования.Результаты и обсуждение. Длительная диагностика заболевания может привести к ухудшению качества жизни и неблагоприятным исходам, таким как плохо контролируемая гипертензия и ее последствия, ТИА, инсульт, диссекция или разрыв аневризмы. Следует отметить, что ФМД может быть обнаружена случайно, когда визуализация выполняется по другим причинам или когда слышен систолический шум при аускультации артерий у бессимптомного пациента без классических факторов риска атеросклероза. По современным рекомендациям пациентам со стенозом почечных артерий при ФМД для лечения гипертонии показано эндоваскулярное лечение, которое дает хороший эффект в улучшении качества жизни.Заключение. Эндоваскулярная баллонная ангиопластика почечной артерии может успешно применяться у пациентов с фибромускулярной дисплазией

Reduced costs with bisoprolol treatment for heart failure - An economic analysis of the second Cardiac Insufficiency Bisoprolol Study (CIBIS-II)

Background Beta-blockers, used as an adjunctive to diuretics, digoxin and angiotensin converting enzyme inhibitors, improve survival in chronic heart failure. We report a prospectively planned economic analysis of the cost of adjunctive beta-blocker therapy in the second Cardiac Insufficiency BIsoprolol Study (CIBIS II). Methods Resource utilization data (drug therapy, number of hospital admissions, length of hospital stay, ward type) were collected prospectively in all patients in CIBIS . These data were used to determine the additional direct costs incurred, and savings made, with bisoprolol therapy. As well as the cost of the drug, additional costs related to bisoprolol therapy were added to cover the supervision of treatment initiation and titration (four outpatient clinic/office visits). Per them (hospital bed day) costings were carried out for France, Germany and the U.K. Diagnosis related group costings were performed for France and the U.K. Our analyses took the perspective of a third party payer in France and Germany and the National Health Service in the U.K. Results Overall, fewer patients were hospitalized in the bisoprolol group, there were fewer hospital admissions perpatient hospitalized, fewer hospital admissions overall, fewer days spent in hospital and fewer days spent in the most expensive type of ward. As a consequence the cost of care in the bisoprolol group was 5-10% less in all three countries, in the per them analysis, even taking into account the cost of bisoprolol and the extra initiation/up-titration visits. The cost per patient treated in the placebo and bisoprolol groups was FF35 009 vs FF31 762 in France, DM11 563 vs DM10 784 in Germany and pound 4987 vs pound 4722 in the U.K. The diagnosis related group analysis gave similar results. Interpretation Not only did bisoprolol increase survival and reduce hospital admissions in CIBIS II, it also cut the cost of care in so doing. This `win-win' situation of positive health benefits associated with cost savings is Favourable from the point of view of both the patient and health care systems. These findings add further support for the use of beta-blockers in chronic heart failure

Cause of Death and Predictors of All-Cause Mortality in Anticoagulated Patients With Nonvalvular Atrial Fibrillation : Data From ROCKET AF

M. Kaste on työryhmän ROCKET AF Steering Comm jäsen.Background-Atrial fibrillation is associated with higher mortality. Identification of causes of death and contemporary risk factors for all-cause mortality may guide interventions. Methods and Results-In the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) study, patients with nonvalvular atrial fibrillation were randomized to rivaroxaban or dose-adjusted warfarin. Cox proportional hazards regression with backward elimination identified factors at randomization that were independently associated with all-cause mortality in the 14 171 participants in the intention-to-treat population. The median age was 73 years, and the mean CHADS(2) score was 3.5. Over 1.9 years of median follow-up, 1214 (8.6%) patients died. Kaplan-Meier mortality rates were 4.2% at 1 year and 8.9% at 2 years. The majority of classified deaths (1081) were cardiovascular (72%), whereas only 6% were nonhemorrhagic stroke or systemic embolism. No significant difference in all-cause mortality was observed between the rivaroxaban and warfarin arms (P=0.15). Heart failure (hazard ratio 1.51, 95% CI 1.33-1.70, P= 75 years (hazard ratio 1.69, 95% CI 1.51-1.90, P Conclusions-In a large population of patients anticoagulated for nonvalvular atrial fibrillation, approximate to 7 in 10 deaths were cardiovascular, whereasPeer reviewe

Neoatherosclerosis in the stent

Achievements of interventional cardiology in the treatment of coronary artery disease are based on coronary balloon angioplasty with implanting bare metal stents and drug eluting stents. Questions of complications such as early stent thrombosis and restenosis of stent were solved in a considerable degree. However, with the lengthening of the followup period, the problem of late complications became obvious. Except endothelization and fibromuscular proliferation in stented coronary arteries the process of plaque formation has an important influence on later complications in follow-up period more than one year. This process was defined as neoatherosclerosis. This is verified by clinical manifestations of the disease, histological studies, angioscopy, intravascular ultrasound and optical-coherence tomography in stented patients. Dynamic observation of the condition in stentedcoronary arteries showed multistep proliferation with restenosis, its regression, and neoatherosclerosis development. Evidences of neoatherosclerosis formation in stented coronary arteries are considered in this review.</p

Clinical condition and cardiovascular risk factors displaying neoatherosclerosis in stented coronary arteries with developing restenosis

Aim. To study the significance of clinical parameters and cardiovascular risk factors (CVR) for restenosis development at long terms after percutaneous coronary intervention (PCI) as a possible displaying of neoatherosclerosis development (NA).Material and methods. Totally, 155 patients after coronary stents implantation, bare and drug eluting, who then, according to clinical profile, underwent second (follow-up) coronary arteriography (CAG) and/or PCI at the timeline of ~4 years. All patients were selected to groups according to restenosis development and time spent before the second procedure (before and after 9 months): group 1 (n=67) — short term follow-up (&lt;9 months) and absence of restenosis; group 2 (n=26) — short period with restenosis; group 3 (n=43) — long term (&gt;9 months) and absence of restenosis; group 4 (n=19) — long term and restenosis (probable NA).Results. Comparison of clinical data and CVR showed that hypodynamia/ abdominal obesity were more prevalent in the group 1 — 20,90%/11,94%, respectively, and group 3 — 13,95%/11,63%, than in group 4 — 5,26%/5,26% and were completely absent in group 2 (p=0,011). Second PCI at the follow-up was done significantly more commonly in restenosis: gr.1/gr.3 — 68,66%/58,14%, gr.2/gr.4 — 84,62%/89,47% (p=0,028). Diagnosis “acute coronary syndrome” in “follow-up CAG/PCI” was significantly more common in delayed restenosis as a display of possible NA — group 4 — 31,58%, comparing to other groups of patients: group 1 — 14,93%, group 2 — 11,54%, group 3 — 4,65% (p=0,043). Other risk factors: arterial hypertension, hypercholesterolemia, diabetes mellitus, insulin dependency, chronic renal failure, smoking, alcohol abuse, family cardiovascular anamnesis, body mass index, — did not show statistically significant differences between the groups.Conclusion. Neoatherosclerosis as the possible element of restenosis at long terms of coronary stenting, in difference from earlier restenosis, presented with more frequent acute clinical conditions. There were no significant difference by CVR factors

Long-term prognosis of CHD depends on fat tissue levels of lipophylic antioxidants and polyunsaturated fatty acids in patients with acute myocardial infarction

To assess influence of the natural fat tissue levels of lipophylic antioxidants and polyunsaturated fatty acids (PUFA) in patients with acute myocardial infarction (MI), on coronary heart disease (CRD) progression. Sixty patients, who had MI in 1991-92, were surveyed and included into the main group of EURAMIC study. According to the variants of CHD progression (death, recurrent MI, stroke, myocardial revascularization), all participants were divided into two groups: 25 individuals without CHD progression (Pr-), and another 35 - with CHD progression (Pr+). To study complex influence of traditional CVD risk factors, lipophylic antioxidants and PUFA levels on the long-term prognosis, as well as for assessing the individual input of each variable, multiple regression analysis was used. The results obtained have demonstrated the following: 1. Carotinoid and PUFA levels in fat tissue of acute MI patients did influence the long-term prognosis of CHD. 2. In patients with MI, decreased level of low-density lipoprotein cholesterol was a significant predictor of poor prognosis. 3. In initially normostenic MI patients, further increase in body mass index associated with worse CHD prognosis

Clinical and angiography factors influencing long-term coronary stenting results

Aim. To study long-term results of coronary artery (CA) stenting, according to baseline clinical and coronaroangiography (CAG) data. Material and methods. The study included 66 males who underwent coronary stent implantation. One to three years later, all participants were retrospectively divided into several groups. Patients without coronary events (CE) comprised CE- Group (n=44), patients with CE – CE+ Group (n=22). Second CAG was performed in 49 patients with 56 stent-implanted CA. CAG signs of restenosis were not found in 35 stenting cases (Restenosis- Group), being registered in 21 stenting cases (Restenosis+ Group). Stepwise multiple regression was used for analyzing the results obtained. Results. After stent implantation, CE risk was affected by smoking status, number of hemodynamically significant stenoses, low diameter of stented CA, balloon inflation time, and minimal effective intervention (MEI) level. Restenosis risk was linked to unstable angina presence, serum triglycerides level, stenosis type, MEI, and low increase in CA diameter after stenting. Conclusion. In selecting treatment tactics for coronary heart disease patients, and assessing the risk of adverse outcomes after CA stenting, a complex of factors affecting CE and restenosis rates should be taken into account, as well as minimally traumatic technique of coronary stenting should be used