PROFESSOR VALENTINA PAVLOVNA KLESHCHEVNIKOVA (to the 100 th anniversary of the birth)

Surgery, as well as almost all sections of medicine, has always been a man’s affair. Valentina Pavlovna Kleshchevnikova (1919–2009), one of the few women who became a professor of surgery, stood out in the mid-20th century galaxy of surgeons. October 2019 marks the 100th anniversary of her birth. Having started her professional career during the Great Patriotic War in a military hospital, she gained experience and knowledge in many areas of surgery. Professor Sergey Vladimirovich Heinatz, her mentor and teacher, had extensive experience in esophageal surgery and while still working in Khabarovsk made – one of the first in the country – esophagoplasty resection with one-stage esophagoplasty. Professor V. P. Kleshchevnikova, a promising surgeon, was also involved in the development of this very difficult field of surgery. It was the material that formed the basis for the candidate’s and later doctoral dissertation of a young, but already experienced specialist. After defending her thesis, V. P. Kleshchevnikova, a young doctor of medical sciences, was elected by competition to head the Department of Hospital Surgery at Petrozavodsk State University (Petrozavodsk). For a long time almost all the leading surgeons of Petrozavodsk and the Republic of Karelia were her students or students of the Department headed by V. P. Kleshchevnikova – someone listened to her lectures, someone worked with her in the clinic or had the honor to «get» Valentina Pavlovna as a mentor or opponent for the defense of the thesis. In Saint Petersburg, at the Mariinsky Hospital, and later at Petrozavodsk State University, a prominent and very bright part of Professor Kleshchevnikova’s surgical and scientific career took place. She was a worthy representative of the pleiad of the most brilliant surgeons, and if we take female surgeons, she was probably the most outstanding surgeon

COMPARATIVE CHARACTERISTICS OF CLASSICAL AND EVERSION ENDARTERECTOMY OF THE CAROTID ARTERIES

Purpose. The effectiveness of classical and eversion carotid endarterectomy (CE) in patients with cerebral ischemia in atherosclerotic stenosing carotid artery disease (ICA) was compared in the article.Material and methods. The examination and analysis of data of 122 patients with more than 60% ICA stenosis was held: men — n = 92 (60.1%), women n = 61 (39.9%). The average age was 52.3 years (ranged from 34 to 74 years). All the patients were symptomatic. 92 patients underwent an eversion endarterectomy (CE), 30 patients underwent classical CE.The effectiveness of surgical treatment was assessed by the dynamics of the neurological status, the change in the parameters of duplex and transcranial studies before the operation, on day 10, at 1, 3, 6, 9 months, 1, 1.5, 2, 3 years.Results. In patients who underwent eversion CE, in the early postoperative period, a significant decrease in the asymmetry coefficient was revealed in the study of background LSC valuesdue to an increase in the blood flow velocity in the ipsilateral middle cerebral artery (MCA) and a decrease in the linear velocity of the blood flow (LVBF) in the posterior cerebral artery (PCA) on the side of the initially stenotic ICA on the background of improvement of hemodynamic conditions in all cases (p < 0.05). In patients, a significant increase in the reactivity factor for the hypercapnic load from the initial value was noted against the background of approaching the normative indices of the pulsation index. The latent period of vascular reactivity was shortened to 24.3 ± 3.7 seconds. In patients who underwent classical CEAE n = 30, in early terms of up to 1 month, a decrease in the coefficient of asymmetry of LVBF was noted due to the normalization of the velocity characteristics of cerebral blood flow in all the main cerebral vessels of the carotid and vertebrobasilar basins. Comparative analysis of the spectral expansion (SE) values obtained initially and recorded in groups with different types of surgical intervention revealed a significant difference in the resulting data (p < 0.05). Restoration of SE parameters to normative ones was registered in the group of classical CEA in 26.7% (n = 8) and 79.3% (n = 73) with an eversion EAE for 1 month. The maximum rate of positive dynamics was traced during the first month after cerebral revascularization, complete recovery was recorded at the end of the 18th month in the group of eversion CE and 24 months in the group of classical CE. There were no significant differences in the resultant indices of regression of neurological disorders in the postoperative period of an eversion EAE and classical EAE (p > 0.05).With the eversion CE, the total number of complications was n = 9 (9.8%), and 1 (1.1%) case — restenosis in the reconstruction zone. In the case of classical CE, the total number of complications was n = 10 (33.3%), of which n = 1 (3.3%) cases of hyperperfusion syndrome were observed; in n = 2 (6.6%) patients, development of a stroke, 1 (3.3%) developed myocardial infarction. Restenosis in the reconstruction zone was formed in n = 2 (6.6%) patients, peripheral nerve damage was in n = 4 (13.3%) patients.Conclusions. Classic and eversion CE are both effective. Short- and long-term clinical and hemodynamic results of surgical treatment by the method of eversion of the CE are somewhat better than the results of classical one.Classical CE is indicated in cases of extended plaque, eversion of the CE is indicated in the cases of short local plaques

NEUROPHYSIOLOGICAL EVALUATION OF THE EFFECTIVENESS OF EARLY CAROTID ENDARTERECTOMY IN ATHEROTHROMBOTIC STROKE

INTRODUCTION. At present, the advantages of surgical treatment over conservative methods in patients with hemodynamically significant stenosis of the carotid arteries are actively discussed. Nowadays, the main discussion issues are the time from the beginning of the stroke to the operation and the criteria for selecting patients for surgical intervention. In recent years, neurophysiological methods for studying spontaneous and evoked brain activity, which are able to identify functional disorders that have important prognostic significance, have become the most relevant.OBJECTIVE. To study the dynamics of spectral-coherent parameters of EEG and somatosensory evoked potentials in patients with ischemic atherothrombotic stroke of different severity, who were performed carotid endarterectomy on the heart attack side in an acute period.METHODS AND MATERIALS. We examined 105 patients with ischemic stroke who underwent carotid endarterectomy in the acute period, analyzed the dynamics of spectral, coherent characteristics of EEG and amplitude-latency parameters of somatosensory evoked potentials in the postoperative period.RESULTS. The dynamics of power spectra, intra-hemispheric EEG, latency and amplitude of somatosensory evoked potentials and clinical parameters were compared.CONCLUSION. It is shown that significant suppression of alpha activity power on the side of both hemispheres, decrease of intra-hemispheric coherence and amplitude of N20-P23 on the side of clinically intact hemisphere in the period up to 3 weeks after surgery determines a longer recovery of neurological deficit in the postoperative period

SUCCESSFUL TREATMENT OF DISSECTION OF THE INTERNAL CAROTID ARTERY

The clinical observation of a successful treatment of a young patient with intima dissection of the internal carotid artery and thrombosis of the lumen of the internal carotid artery and the middle cerebral artery of traumatic genesis is presented. Injury of the internal carotid artery occurred with a large physical load of a rotational nature. Fracture of the styloid process caused a dissection of the internal carotid artery with its thrombosis on the extracranial level and the development of ischemic stroke in the basin of this artery. In an emergency order, a complex of diagnostics was performed-CT CT, CT angiography. The first stage was performed thrombextracion from the internal carotid artery and the middle cerebral artery by the X-ray endovascular method. To fix the intima in the internal carotid artery in the area of her injury we stented her. Complete revascularization was achieved in the basin of the internal carotid artery with almost complete regression of neurologic symptoms. The patient returned to work. The use of x-ray endovascular mini-invasive technologies, thrombus extraction and stenting in the next few hours after the development of AVCC allowed to achieve a good near and distant clinical result

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

RARE CAUSES OF ISCHEMIC STROKE. FEATURES OF ACUTE STROKE IN PATIENTS WITH DISSECTION OF THE GREAT VESSELS

Purpose of the study. Identification of the main causes of ischemic stroke in patients with aortic dissection, features of the clinical picture, the choice of optimal tactics for the management of such patients.Patients and methods. During 2017, 11 patients with aortic dissection were hospitalized for emergency indications and underwent complex, surgical interventions. In 4 patients, the reason for hospitalization was ischemic stroke, in 7 patients, the onset of the disease was manifested by chest pain. Subsequently, in all cases, ischemic stroke developed within 48 hours from the onset of pain symptoms. Fatal outcomes occurred in 5 (45.45%).Results. All patients were operated on for aortic dissection. Various types of surgery were performed. The best results were achieved with a hybrid operation — prosthetics of the aortic arch with endoprosthetic replacement of the de­scending aorta. The main reason for the development of ischemic stroke with aortic dissection and surgery for its elimi­nation is the development of brain malfunction. The cause of death was the dissemination of the dissection into the vis­ceral arteries with the development of multiple organ failure or aortic rupture of the aorta with hemo tamponade.Conclusion. As a rule, several pools of blood supply to the brain, episodes of psychomotor excitement are involved in the dissection of the aorta and branches of the aortic arch, cognitive impairments are progressing, since cortical branch­es of the brain are usually involved. With the timely assignment of neuroprotective therapy, revascularization, early complex rehabilitation, there is a significant positive dynamics of neurological status, restoration of cognitive functions

Repeated operations in patients with unsatisfactory results of celiac artery compression syndrome treatment

Purpose of the study. The reasons for the unsatisfactory results of surgical treatment of patients with celiac artery compression syndrome (CACS) and the role of repeated interventions allows to achieve a lasting improvement in most of them. The purpose of the study is to clarify the reasons for the unsatisfactory outcomes of surgical treatment of patients with CACS and the nature and significance of repeated operations.Patients and methods. From 860 patients with CASC who were operated on over the past 25 years 82 patients were selected with unsatisfactory treatment results. Initial conventional abdominal surgery was performed in 26 (31.7%) patients without a positive outcome before decompression of celiac artery (DCA). Primary operations were performed in 82 patients with proven CASC, of which 69 (84.1%) had DCA in open approach, isolated in 43 (52.4%) and combined in 26 (31.7%). Embolization of PDA aneurysm in one (1.2%) patient. In other medical institutions 15 (18.3%) patients were operated, among them 3 (3.7%) patients had DCA in open approach, in 4 (4.9%) laparoscopic DCA, in 6 (7.3%) angioplasty and emergency stenting and two (2.4%) reconstructive operations, all technically and clinically unsuccessful.Results. After DCA in open approach 51 (73.9%) patients of 69 patients had normal celiac artery flow. 4 patients had unresolved stenosis of the celiac artery and 15 relapsed its stenosis, one of them with residual stenosis after DCA twice, which amounted to 0.5% and 1.7%, respectively of 860 patients. Repeated operations were performed in 51 (62.2%) patients out of 82 to restore the celiac artery in 28 (34.2%), among them 4 (4.9%) in combination with interventions on the abdominal organs. Abdominal operations with concomitant diseases of the gastrointestinal tract with normal flow in celiac artery in 21 (25.6%).Scalenotomy in two (2.4%). Of 28 patients, re-revascularization of the celiac artery was successful as a result of open decompression in 7 out of 8, bypass surgery in 9 out of 10 and balloon angioplasty and with stenting in two out of 7. One had an effective primary DCA and the other resected PDA aneurysm. 19 patients out of 25 showed a good result after operations on the abdominal organs.Conclusion. The unsatisfactory results of surgical treatment of patients with CASC are associated with inadequate restoration of celiac artery restenosis and/or concomitant diseases of the abdominal organs. Repeated vascular operations are mainly: decompression of celiac artery in open approach, bypass surgery and balloon angioplasty and stenting, and/or abdominal mainly: cholecystectomy, NissenFP, and Strong surgery are of primary importance in the treatment of patients with CASC