Abstract

Background: ongoing abdominal and pelvic bleeding is one of main causes of deaths among patients with penetrating and blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary patient's stabilization and reducing blood loss.

Aim: was to present result of work of 1st-level trauma-center: to describe experience of application of methodics of REBOA in center, to estimate its efficacy on the base of retrospective analysis of hospital charts of injured and heavy damaged patients.

Materials and methods: during the period between April 2013 and November 2017, 14 REBOA procedures to patients with abdominal (thoracic aorta occlusion) and pelvic (occlusion of the aortic bifurcation) bleeding were performed at the War Surgery Department of the «KirovMilitaryMedicalAcademy». A decision to do REBOA was made upon admission according to significant hypotension (systolic blood pressure [sBP] less than 70 mm Hg.) or cardiac arrest, abdominal free fluid and/or mechanically unstable pelvic fractures.

Results: mean time from admission to REBOA was 27,5 [10,0-52,5] minutes. The procedure took 10 [5-13] minutes. Average BP elevation after balloon inflation was 43±16 mm Hg. Survival in acute phase of trauma (first 12 hours) was 57.1%, while total survival rate was only 14.3% (2/14 patients). One REBOA-associated major complication was registered - development of irreversible ischemia due to long sheath dwell time in the femoral artery.

Conclusion: REBOA is effective for temporary hemodynamic stabilization and internal hemorrhage control, it allows increasing early survival in severe trauma. Factors to improve short- and long-term outcome, total survival warrant to be additionally investigated, especially in terms of intensive care improvement.

References

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15.     Ogura T., Lefor A.T., Nakano M. et al. Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta. J. Trauma Acute Care Surg. 2015; 78 (1): 132-135

Abstract

Aim: was to estimate condition of aorta branches in case of aortic dissection, using multislice computed tomography (MSCT): we estimated frequency and type of changes of main branches of the aorta involved in the dissection.

Material and methods: a retrospective analysis of 104 patients with aortic dissection (AD) was performed. All patients were admitted to Scientific-Research Institute of Emergency Medicine named after N.V Sklifosovsky All studies were carried out on a multispiral (80x0.5) tomograph in early stages of the disease.

Results: MSCT method allowed to obtain data of the high frequency of transition of aortic dissection to main branches (63.5%), mainly to iliac arteries (81% and 77% of aortic dissection type A and B respectively), both in isolation and in combination with other branches. However, the frequency of occurrence of hemodynamically significant stenosis, both static and dynamic, was significantly higher in groups of visceral branches and brachiocephalic arteries (82% and 71%, respectively).

Conclusion: the CT method allows to evaluate in detail the lumen of the aorta and branches of aorta, and to determine type and degree of stenosis of aortic branches involved in the dissection. Revealed patterns of combining of involvement in different groups of aortic branches in the pathological process, allow to procced more optimized diagnostic search for complications of dissection, including MSCT.

References

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2.     Litmanovich D, Bankier AA, Cantin L, Raptopoulos V. Boiselle PM. CT and MRI in Diseases of the Aorta. Am J Roentgenol. 2009;193(4):928-940. PMID:19770313 https://doi.org/10.2214/ajr.08.2166

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4.     Borst HG, Heinemann MK, Stone CD. Surgical treatment of aortic dissection. Churchill Livingstone International; 1996.

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6.     Gamzaev AB ogly, Pichugin VV, Dobrotin SS. Diagnosis, surgical treatment tactics and methods for ensuring operations for aortic dissection. In: Medvedev AP, Pichugin VV. Emergency heart surgery: current and unresolved issues. Nizhny Novgorod; 2015.p.237-281. [In Russ]. 

7.     Belov YuV, Komarov RN, Stepanenko AB, Gens AP Savichev DD. Common sense in determining indications for surgical treatment of thoracoabdominal aortic aneurysms. Pirogov Russian Journal of Surgery. 2010;(6):16-20. [In Russ].

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10.   Strayer RJ, Shearer PL, Hermann LK. Evaluation, and early management of acute aortic dissection in the ED. Curr Cardiol Rev. 2012;8(2): 152-157. PMID:22708909 https://doi.org/10.2174/157340312801784970

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12.   Chiu KW, Lakshminarayan R, Ettles DF. Acute aortic syndrome: CT findings. Clin Radiol.2013;68(7):741-748. PMID:23582433 https://doi.org/10.1016/j.crad.2013.03. 001

13.   Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo R, Eggebrecht H, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases. Europ Heart J. 2014 35(Is 41 ):2873-2926. PMID:25173340 https://doi.org/10.1093/eurheartj/ehu281

14.   Lansman SL, Saunders PC, Malekan R, Spielvogel D. Acute aortic syndrome. J Thorac Cardiovasc Surg. 2010; 140 (6Suppl): S92-97. PMID:21092805 https://doi.org/10.1016Zj.jtcvs.2010.07.062

15.   Bonaca MP, O'Gara PT. Diagnosis and management of acute aortic syndromes: dissection, intramural hematoma, and penetrating aortic ulcer. Curr Cardiol Rep. 2014;16(10):536. PMID:25156302 https://doi.org/ 10.1007/s11886-014-0536-x

16.   Tsai TT, Nienaber C, Eagle KA. Acute Aortic Syndromes. Circulation. 2005; 112(24): 3802-3813. PMID: 16344407 https://doi.org/10.1161/circulationaha.105.534198

17.   Strayer RJ, Shearer PL, Hermann LK. Screening. evaluation, and early management of acute aortic dissection in the ED. Curr Cardiol Rev. 2012;8(2): 152-157. PMID: 22708909 https://doi.org/10.2174/ 157340312801784970

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23.   Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. Kardiol Pol. 2014;72(12):1169-252. PMID:25524604 https://doi.org/10.5603/kp.2014.0225

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Abstract

Aim: was to define possibilities of multispiral computed tomography (MSCT) in assessment of condition of aorta and it's branches, during preparation for reconstructive surgery in patients with horseshoe kidney.

Material and methods: for the period 2015-2018, 415 patients were examined during preparation for aortic reconstructive surgery. Patient underwent target ultrasonic diagnostics, followed by computed tomography made on 256-slice Philips iCT, before and after injection of contrast agent. We used a special program for comparing various phases of the study ("Fusion") for better visualization of arterial vessels of kidney, aorta and renal excretory system. In 5 cases, a combination of aortic pathology with abnormal horseshoe kidney was revealed.

Results: in all cases we revealed branched type of blood supply of abnormal kidney A total of 5 patients had 25 renal arteries. In 4 cases we revealed branched type of renal veins, its total ammount was 20. Duplication of upper urinary tract was found in 1 case. From the surveyed group, 3 patients out of 5 were operated. Intraoperatively all data detected by CT scan regarding the condition of the aorta, the position of the kidney, the number of renal vessels were confirmed.

Conclusion: MSCT allows detailly assessment of anatomical features of abnormal horseshoe kidney and facilitates subsequent surgical intervention in patients with a rare combination of aortic pathology and a horseshoe kidney.

References

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10.     Troickij V.I., Habazov R.I., Lysenko E.R. i dr. Surgical treatment of abdominal aortic aneurysm in a patient with a horseshoe-shaped kidney. Angiologiya i sosudistaya hirurgiya. 2003; 9 (2): 122-125. [In Russ.]

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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3.      Bartram U., Granenfelder J., Van Praagh R. Causes of death after the modified Norwood procedure: a study of 122 postmortem cases. Eur. Vasc. Endovasc. Surg. 2017; 53(5):617-625.

4.      Vitanova K., Cleuziou J., Pabst von Ohain J. et. al. Recoarctation After Norwood I Procedure for Hypoplastic Left Heart Syndrome: Impact of Patch Material. Ann. Thorac. Surg. 2017; 103(2):617-621.

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Abstract:

At 246 patients with coarctation of the aorta the ultrasonic semiotics of disease has been investigated. Are systematized echocardiographycal attributes of defect: are determined direct and indirect (displays directly reflecting morphology), the estimation of their sensitivity and specificity is lead. The certain combination of the specified attributes has allowed to allocate three variants of a ultrasonic picture coarctation of the Aorta, reflecting various anatomic forms of defect. The semiotics and diagnostic attributes of each ultrasonic variant of defect is described by echocardiography. 

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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:

Purpose. To assess early and late results of iliac arteries balloon angioplasty and stenting in patients with chronic lower limb ischemia.

Material and methods. We analyzed the results of terminal aortic and iliac lesions endovascular treatment in 222 patients. All the patients presented symptoms of lower-limb chronic ischemia: 2nd «b» grade - 51,2%; 3rd grade - 27,1%; 4th grade - 21,7%. Two hundred and fifty eight procedure were performed, including 98 (38%) balloon angioplasty and 160 (62%) stenting. The lesions were Type A -26%, Type B - 45%, Type C - 23%, and Type D - 51% according to TASC II classification.

Results. Immediate angiographic success rate was 99,4%, complication rate -1,3% (4 of 314). Cumulative primary patency after balloon angioplasty in terms of 1, 3 and 5 years were correspondingly 97,9%, 82,0% and 64,2%. After stenting it was as high as 98,1%, 85,2% and 71,8%. Secondary patency after balloon angioplasty in terms of 1, 3 and 5 years was correspondingly 99,0%, 89,4% и 75,6%. For stenting it was 99,4%, 93,0% and 85,6% (Kaplan - Meier). Long-term clinical success rates in 1 year, 3 and 5 years were correspondingly 97,9%, 98,7% and 88,8% for angioplasty and 92,6%, 63,7% and 72,6% for stenting. Five-year limb preservation rate was 92,4% for angioplasty and 98,6% for stenting.

Conclusions. Endovascular interventions are proved to be safe and efficient for iliac arteries atherosclerotic lesions, and to have good long-term results. 

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            11.  Затевахин И.И., Дроздов С.А., Хабазов Р.И. Допплеросфигмоманометрия в диагностике поражений глубокой артерии бедра. Клиническая хирургия. 1985; 7: 24-2

Abstract:

Background: balloon angioplasty for coarctation of the aorta (CoA) in teenagers and adults is sometimes limited by significant residual pressure gradient (>20 mm Hg) in cause of vesse «elastic recoil». To avoid this complication intervention cardiologists use self- and balloon-expandable endovascular stents. In this report we demonstrate our experience in such method of aortic coarctation repair.

Materials and methods: in our instituton since December 2008 to Desember 2013 85 teenagers and adult patients were treated by endovascular stent placement to coarctatec aortic segment. The age of patients was 10 to 60 years (mean 20,3+7,4), weight 20 to 90 kgs (mean 53,2+14,6). Mean systolic arterial pressure was 166+7mm Hg. (range 140 to 200), mean systolic pressure gradient (SPG) was 60,6+9,0 mm Hg (range 25 to 85). The mean cross section at baseline of coarctation was 19,6±6,1 mm2 (range 1 to 95). 61 patients had native coarctation and 3 recoarctation after previous surgical repair. In 21 cases coartation was in combination with other cardiac pathology - patent ductus arteriosus (PDA), restrictive VSD, aortric and mitral valve lesions, and coronary vessel pathology Seven patients had hemodynamically significant aortic atresia. We used 20 Palmaz P-4014, 18 Genesis XD PG-2910 (Cordis Jonson & Jonson) and 45 - CP, CP covered stents, one - Intratherapeutic Doublestrut (EV3), and one Advanta V12 (Atrium) covered stent.

Results: 90 stents were implanted in 85 patients. Procedure was successful in all but one cases, one patient with postsurgical recoarctation had residual systolic pressure gradient > 25 mm Hg after stent placement. The peak systolic gradient decreased from a mean value of 60 mm Hg.(range 25 to 85) to a mean 7 mm Hg (range 0 to 25). Systolic blood pressure normalized in 64 cases, twenty one patients require additional drug therapy Coarctation site cross section increased from a mean of 19,6 mm2 to 236,3 mm2. PDA was closed simultaneously with the stenting by coils, and for eleven patients with other cardiac malformations endovascular coarctation repair was as a first step in complex cardiac surgical treatment. In one case of 56 years old male we had acute aortic dissection which was stabilized without surgical intervention. Two patients with complete hemodynamically significant aortic atresia developed stent fracture, which was recognized on CT scan 6 months after procedure. In one case it was treated with covered stent placement. In another patient stent fragment was treated surgically We had three stent migration with their safe deployment in thoracic aorta and followed by successful repair of aortic narrowing with additional stent.

Conclusion: stent implantation for aortic coarctation is safe and effective procedure. The early and intermediate term result are encouraging, with relatively low incidence of complication in teenagers and adult patients. 

References

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2.     Carr J. The Results of Catheter-Based Therapy Compared With Surgical Repair of Adult Aortic Coarctation. J. Am. Coll. Cardiol. 2006, 47: 1101-1107.

3.     Mullen M.S. Coarctation of the aorta in adults: do we need surgeons? Heart. 2003; 89: 3-5.

4.     Forbes T.J. Procedural Results and Acute Complications in Stenting Native and Recurrent Coarctation of the Aorta in Patients Over 4 Years of Age A Multi-Institutional Study. Cath. and Cardiovascular. Interventions. 2007; 70: 276-285.

5.     Golden А^. Coarctation of the Aorta: Stenting in Children and Adalts. Cath. and Cardiovascular Interventions. 2007; 69: 289-299.

6.     Chessa M., Carrozza M., Butera G., Piazza L., Carminati M. Results and mid-long-term follow-up of stent implantation for native and recurrent coarctation of the aorta. European Heart Journal. 2005; 26: 2728-2732.

7.     Rosenthal E. Stent implantation for aortic coarctation: the treatment of choice in adults? J. Am. Coll. Cardiol. 2001;38: 1524-1527.

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9.     Qureshi S.A. Stenting in aortic coarctation and transverse arch/isthmus hypoplasia; Percutaneous Interventions for Congenital Heart Disease, 2007: 475-489.

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Abstract:

Article describes experience of Novosibirsk scientific-research institute of blood circulation pathology named after E.N.Meshalkin in hybrid interventions in aortic dissection.

Aim: was to estimate efficacy of hybrid methods in surgical treatment of aortic dissection .

Materials and methods: since 2011 - 17 operations on proximal aortic dissections and 8 operations on distal aortic dissection with use of hybrid methodics were made.

Results: mortality in early post-operative period - 2 patients and was determined by progression of heart insufficiency In late post-operative period, basing on MSCT data, thrombosis of false lumen of aortic dissection on the mark of stent-graft or bare-metal stent (descending thoracic aorta) was revealec in 7 of 10 patients (70%) and in all patients with hybrid endoprothesis. During observation in post-operative period, none of patients were marked as needed of operation on thoracic-abdominal aorta.

Conclusion: used techniques allow to gain number of advantages in this severe group of patients as n early post-operative period, and also in late post-operative period. Endovascular treatment, performing simultaneously with open surgical interventions - are safe for patient and easy for surgeon. More extended reconstruction of aorta in single-stage operation can exclude aneurysmatic degeneration and prevent operations on distal aorta. 

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Abstract:

The article presents the experience of endovascular treatment of abdominal aortic atherosclerotic lesions using different types of stents, performed in the Central Military Clinical Hospital named after A.A.Vishnevskogo.

Materials and methods: nine patients underwent 11 operations - stenting of aorta. Direct stenting of terminal aorta was performed in 5 patients, 4 - bifurcation stenting of aorta and both iliac arteries. Endovascular surgery combined with the "open" reconstruction of arteries below the inguinal ligament (hybrid operation) were performed in 2 cases.

Results: technical perioperative success of interventions with the restoration of the aortic lumen was achieved in all cases. Our experience in endovascular treatment of atherosclerotic lesions of the abdominal aorta, allows to characterize this surgical intervention as a highly effective and low-impact.

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8.     Gavrilenko A.V., Egorov A.A. Tradicionnaja hirurgija sosudov i rentgenjendovaskuljarnye vmeshatel'stva - konkurencija ili vzaimodejstvie, vedushhee k gibridnym operacijam? [Traditional angiosurgery and endovascular procedures - competition or cooperation] Angidogija i sosudistaja hirurgija. 2011; 17(4): 152-156 [In Russ].

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Abstract:

Endovascular treatment of thoracic aortic dissection type B is the method of choice in complicated cases. These interventions are obviously less traumatic, accompanied by less blood loss, shorten the length of stay in the intensive care unit, and there is a smaller number of complications. Successful treatment requires careful planning and determination of the existence of conditions for the implantation of endovascular prostheses. It is important to analyze the question of vascular approach, the availability of landing zone, the feasibility of switching aorta branches before implantation etc. However, you can have experience of not predicted of intraoperative complications. 

Article presents two clinical cases of implantation of stent-grafts in patients with challenging anatomy of the defeat of the thoracic aorta. In both cases, we used hybrid approach. In each case we used carotid-subclavian shunting before implantation of the stent-graft and in one case we usee «chimney» technique. Thoracic Endovascular Aortic Repair in these patients was accompanied by certain difficulties. Anatomical difficulties were overcome by using of not standart technique during operation.

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