Abstract:

In recent years, with the growth of number of patients with multifocal atherosclerosis, revascularization of the brain and myocardium through hybrid intervention is gaining popularity. Although, in the world literature there are practically no results of significant randomized researches concerning percutaneous coronary intervention and carotid endarterectomy in hybrid mode, this technique is becoming more and more preferable and promising in comparison with other methods of treatment.

Aim: was to demonstrate results of revascularization of the brain and myocardium with staged and hybrid strategies, on the base of evaluation of advantages and disadvantages of these strategies on the example of case reports.

Materialsand methods: article presents two case reports, demonstrating different approaches to surgical treatment in patients with combined lesions of arteries of the brain and myocardium. Both patients were over 65 years age, at the time of treatment, had a history of acute cerebral circulation disorders, coronary heart disease and arterial hypertension. At the outpatient stage, they received antiplatelet, hypotensive, and hypolipidemic therapy. During further examination, both patients were found to have unilateral hemodynamically significant stenoses of internal carotid arteries and isolated stenoses of coronary arteries. In first case, patient was selected for hybrid surgical tactics in the volume of carotid endarterectomy and stenting of coronary artery, which was performed with a further favorable prognosis. In the second case, tactics was determined in favor of a staged procedure: first performing carotid endarterectomy, then stenting the affected coronary artery. However, taking into account subjective and objective factors, none of planned interventions were performed.

Results: hybrid revascularization allows to perform correction in two arterial of different regions in a short period of time using surgical and endovascular techniques. An important advantage of this method is the one-time performance, that means correction of MFA manifestations for one hospitalization, or even one anesthesia, with increasing in the availability of revascularization. In the first case report, the successful implementation of a hybrid approach in the treatment of combined vascular pathology in an elderly patient with a burdened anamnesis and significant comorbidities was demonstrated. Within one day, we managed to complete the planned volume of myocardial and brain revascularization and avoid the development of adverse events both in the early postoperative and long-term follow-up periods. The second clinical example clearly shows disadvantages of staged strategy, when the patient is at risk of developing adverse cardiovascular events while waiting for staged interventions, or for subjective reasons may refuse to be hospitalized in a clinic for performimg a particular operation, that as a result, led to negative dynamics and fatal outcome due to acute stroke.

Conclusions: thus, demonstrated case reports show significant potential and effectiveness of hybrid myocardial and brain revascularization using percutaneous coronary intervention and carotid endarteectomy in treatment of patients with combined lesions of two vascular regions. This method of treatment is especially promising in patients with burdened anamnesis and additional risk factors. It not only prevents adverse cardiovascular events in brain and myocardium, but also has greatest availability and implementation of the planned volume of treatment, completely excluding the influence of subjective factors (change of tactics, failure of patient to attend the next stage of treatment, etc.).

References

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Abstract:

Background: article presents a case of 11-month-old baby weighing 6,590, with phenomena of circulatory decompensation, and non-standard hybrid intervention using retroperitoneal open access to the infrarenal aorta - stent implantation with the potential for increasing its diameter as the child grows

Materials and methods: the patient underwent examination - echocardiography (Echo-CG), multispiral computed tomography (MSCT), angiography Indication for the operation was the restenosis of the distal aortic anastomosis after the stage-by-stage surgical correction of hypoplastic left heart syndrome (Norwood procedure). This tactic was chosen taking into account the extremely high risk of re-surgery, as well as the impossibility of stent implantation with the potential for increasing the diameter through access to the femoral artery (body weight of the child is 6.6 kg). The patient underwent stenting of restenosis of the distal aortic anastomosis through retroperitoneal open access to the infrarenal aorta.

Results: good early postoperative period, against the background of disaggregant therapy (aspirin 5 mg/kg per day) and antibiotic therapy In control echocardiography (Echo-CG), the systolic pressure gradient in the stent implantation zone is 22 mm hg. The patient was discharged to an outpatient stage, followed by examination after 6 months and possible re-intervention (stent dilatation with a larger diameter balloon) as the pressure gradient rises as the child grows. Proposed hybrid approach in a child 11 months with a body weight of 6,590 kg allowed to avoid the risk of re-surgery in conditions of circulatory arrest and demonstrated a satisfactory angiographic and clinical result.

Conclusion: stenting of restenosis in distal aortic anastomosis using retroperitoneal access can be considered as a surgery of choice in specialized centers.

References

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Abstract:

Results of successful surgical treatment of a patient with an extremely rare disease - Parkes-Weber- Rubashov syndrome, manifestating by arteriovenous malformations of the lower limb and spinal cord are presented. Endovascular embolization of arteriovenous malformation of the lower limb was treated with use of three Flipper coils due to the severity of the clinical symptoms. A conclusion about the effectiveness of this method of treatment is presented. 

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Abstract:

We had analyzed percutaneous coronary intervention (PCI) of non-standard complications - coronary artery dissection with extension on the eft main coronary artery (LMCA) and aorta. There was the coronary dissection of LMCA and aorta after left internal thoracic arteries and left anterior descending anastomosis (LIMA-LAD) balloon predilatation. Satisfactory angiographic result was achieved with blood flow TIMI III after stent implantation. In connection with the stable condition of the patient there was no endovascular or surgical treatment. The patient had stable hemodynamics in hospital period. The angiografic control was performed after 8 days. There was no coronary and aorta dissection and stent-thrombosis.

In conclusion in can be said that conservative tactics may be useful in a case of retrograde coronary and aorta dissection after LIMA-LAD stent mplantation.

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Abstract:

Background: There are no randomized trials describing outcomes of multivessel percutaneous coronary interventions (PCI) (in primary anc staged revascularization) with second generation drug eluting stents (DES) in patients with ST-elevation myocardial infarction (STEMI). We are presenting preliminary results of randomized trial (NCT01781715)

Materials and methods: Six-month outcomes of 89 consecutive patients with STEMI and multivessel coronary artery disease (CAD) (SYNTAX 18.6±7.9 points) undergoing primary PCI with zotarolimus-eluting stents (Resolute Integrity; Medtronic) were studied. We used two strategies of multivessel stenting: in primary PCI (MS primary) and multivessel stenting in staged revascularisation (MS staged) (8.5±4.2 days).

Results: We evaluated results in the overall cohort of patients, including two study groups (MS primary and MS staged). During follow-up of 6 months there was no cardiac death in overall group. We observed 3 (3.4%) non-fatal myocardial infarction (MI) due to definite stent thromboses (ST) (1.3% on the number of stents). Target vessel revascularization (TVR) was performed in 2 cases (2.2%). Major adverse cardiac event (MACE) (cardiac death, MI, TVR) was diagnosed in 4.5%.

Conclusions: Resolute Integrity stents in STEMI patients with multivessel CAD are satisfactory safely and effectively as part of the strategy of multivessel stenting in primary PCI and multivessel staged PCI (8.5±4.2 days).

References

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13.   Politi L., Sgura F., Rossi R. et al. A randomised trial of target-vessel versus multi-vessel revascularization in ST-elevation myocardial infarction: major adverse cardiac events during long-term follow-up. Heart.2010;96:662-667.

14.   Varani E., Balducelli M., Aquilina M. et al. Single or multivessel percutaneous coronary intervention in ST-elevation myocardial infarction patients. Catheter Cardiovasc. Interv. 2008;72:927-933.

15.   Roe M.T., Cura F.A., Joski PS. Initial experience with multivessel percutaneous coronary intervention during mechanical reperfusion for acute myocardial infarction. Am. J.Cardiol. 2001;88:170-173.

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Abstract:

Despite the fact that so far in the literature, many cases of endovascular closure of paravalvular leak (PVL), this type of intervention is unusual and is associated with a complex technical issues. In addition, the majority of publications devoted to the correction of mitral and aortic PVL, while the description of the closing of the tricuspid valve (TV) PVL are rare.

Below is a description of our first experience of endovascular correction of TV PVL in 54 years ole patient, who underwent TV repair with «Neokor-32» - supporting ring as a correction of atrial septal defect, TV insufficiency One year after surgery the patient reported a decrease in physical activity tolerance. Echocardiography diagnosed hemodynamically significant PVL of TV, 6mm size with leakage between the left ventricle and the right atrium and formation of pulmonary hypertension. PVL was successfully treated by endovascular correction with using of device for closure of ventricular septal defect.  

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Abstract:

Endovascular correction of atrial septal defect (ASD) has become the «gold standard» of treatment, both in children and adults. In case of complicated anatomy of the defect (multiple defects, its large size, lack of edges, aneurysm of atrial septum), experts often chose surgical correction of such pathology Accumulated experience of interventional cardiology and appearance of specialized tools allow to perform a successful intervention in a non-standart situation.

Article describes cases of a successful endovascular correction of ASD in a two year child and adult patient with complicated anatomy factors. In both cases, during echocardiography, we diagnosed multiple ASD with aneurysm of atrial septum, accompanied by clinical symptoms. During multidisciplinary discussions, we identified indication for endovascular correction of the defect.

We performed successfull correction of ASD with occluder for closure of patent foramen ovale, and complete termination of left-to-right shunt on the operating table.

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Abstract:

Arteriovenous malformation (AVM) of kidney - is rarely seen vascular anomaly, with clinical polymorphism (hematuria, hypertension, left ventricular hypertrophy, heart failure, abdominal pain), and difficult diagnostic algorithms and is often a cause for radical organ-resecting operations (nephrectomy).

Article describes a case report of 37 years old patient with a diagnosis of «arteriovenous malformation of left renal artery», and the clinical picture of hematuria, post-hemorrhagic anemia. Patient underwent ultrasound of kidneys and bladder (no disease found) and multi-slice computed tomography (AVM of upper pole of left kidney, sized 5,4x5,0 cm).

Patient underwent endovascular embolization of AVM with 4 coils «Flipper». Patients was discharged on the 7th day without complications after the control ultrasound and MSCT The use of selective endovascular embolization of renal AVM reduces or removes clinical manifestations, and has lower operational risks, as well as allows you to save the function of the intact portion of renal parenchyma, which don't lead to patient's disability (in comparison with to organ-resecting surgery).

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