Vol 32, No 3 (2024)

INTRODUCTION: Coronary artery disease (CAD) currently remains the leading cause of morbidity and mortality in Russia and in the world. In 2022, the overall morbidity with CAD among the adult population of Russia was 6517.9 per 100 thousand populations. The main surgical methods of treatment for CAD are coronary artery bypass grafting (CABG) and stenting of the coronary arteries. In some cases, a single-step complete revascularization is not possible, and one of solutions is a hybrid approach.

AIM: To compare 5-year results of CABG, staged hybrid myocardial revascularization and isolated endovascular intervention in patients with CAD and multi-vessel lesion of the coronary arteries.

MATERIALS AND METHODS: The prospective study included 330 patients with CAD and multi-vessel atherosclerotic lesion of the coronary arteries, who underwent planned myocardial revascularization in 2010–2018. Group 1 included 110 patients who underwent CABG, group 2 — 110 patients who underwent staged hybrid myocardial revascularization, group 3 included 110 patients after percutaneous coronary intervention. In 5-year follow-up period, clinical and instrumental data were evaluated, complications, lethal outcomes and re-interventions were considered.

RESULTS: In the immediate period after the surgical intervention, frequency of cardiovascular complications and residual myocardial ischemia was expectedly low in all the groups (р > 0.05). At 1 year of follow-up, cardiovascular complications were less common in group 2 (17.3%) compared to group 1 (29.1%, p = 0.038), while in group 3, adverse events were also noted in 27.3% of cases, however, the differences were not significant (p = 0.075). At 5 years, the frequency of cardiovascular complications prevailed in patients of group 1 (80.0%) compared to group 2 (57.3%) and group 3 (67.3%, p = 0.001–0.032). At the end of follow-up, the frequency of repeat revascularization was significantly higher in group 1 (41.8%) compared to group 2 (29.1%, p = 0.049). The number of such cases in group 3 (33.6%) was less than in group 1, however, the differences were not statistically significant (p = 0.125).

CONCLUSION: Isolated CABG demonstrates a higher frequency of repeat endovascular interventions at 5 years after surgery compared to hybrid revascularization that also provides better results in terms of preventing cardiovascular complications.

INTRODUCTION: To date, no consensus has been achieved on the most appropriate surgical method for the treatment of abdominal rectus diastasis concomitant with midline hernias.

AIM: Study of the results of three original methods of surgical treatment of patients with abdominal rectus diastasis concomitant with midline hernias.

MATERIALS AND METHODS: The results of treatment of 74 patients have been analyzed. The patients were divided into three comparable groups: in the first group (n = 25), repair with local tissues with formation of aponeurotic duplication was performed, in the second group (n = 24), autodermal de-epithelialized graft was used, in the third group (n = 25) — mesh sub-lay implants. The following parameters were evaluated: duration of narcotic analgesia in the postoperative period, period of activation of patients, periods of inpatient treatment and results on Clavien-Dindo and EuraHSQoL scales. The follow-up period was from 1 to 10 years after surgery.

RESULTS: The period of postoperative use of narcotic analgesics was 1.08 ± 0.38 days in the first group, 0.98 ± 0.33 days in the second group, 2.13 ± 0.93 days in the third group. The period of activation was 3.00 ± 1.53 days in the first group, 0.89 ± 0.36 days in the second group, 1.5 ± 0.48 days in the third group; the duration of inpatient treatment was 9.24 ± 1.88 bed-days, 6.34 ± 3.04 bed-days and 8.36 ± 2.14 bed-days, respectively. Postoperative complications in the first group were CDI class 6, CDII class 3, in the second group CDI class 1, in the third group CDI class 6, CDII class 3. At 12 months after the operation, painful sensations and functional discomfort on EuraHSQoL scale were absent in the second group, in the first and third groups, limitations in physical activity were noted (р ≤ 0.05; differences between the first and third groups were statistically insignificant, p ≥ 0.05). There were no statistically significant differences in the cosmetic discomfort between the groups (p ≥ 0.05).

CONCLUSION: A safer and more effective method of repair of the anterior abdominal wall in patients with concomitant abdominal rectus diastasis and midline hernias is plastic surgery with application of de-epithelialized autodermal graft.

INTRODUCTION: The introduction of the study is determined by a high prevalence of alcoholism and a high incidence of complications from the cardiovascular system.

AIM: To study the features of hemodynamics in patients with uncomplicated alcohol withdrawal syndrome (AWS) and in those with alcohol withdrawal delirium (delirium tremens).

MATERIALS AND METHODS: The study enrolled 116 men, 58 of them with uncomplicated AWS, 78 with AWS and delirium. Basic hemodynamic parameters were studied: heart rate (HR), blood pressure (BP), and integral parameters — cardiac index (CI), total peripheral resistance (TPR), shock index (SI). Comparisons between the groups and correlation analysis were conducted to find relationships between hemodynamic parameters and clinical data.

RESULTS: In patients with alcoholic delirium, hemodynamic parameters were statistically significantly higher than in patients with uncomplicated AWS: HR (р = 0.003), systolic BP (р = 0.02) and diastolic BP (р = 0.04), while no statistically significant differences in the integral parameters (CI, TPR, SI) were found between the groups. In patients of both groups, CI linearly decreased with age (p < 0.0001). The same linearly CI decreased with increase in the duration of alcoholism (p = 0.02). With an increase in the amount of consumed alcohol during the binge period, a linear growth of CI was observed in withdrawal state (p = 0.001). The value of TPR increased with age (p = 0.005). Only in patients with delirium tremens, there was an inverse relationship between SI and partial tension of carbon dioxide in venous blood (r = -0.4; p = 0.014). Besides, only in patients with delirium tremens, by the 7^th day of withdrawal, a direct relationship was established between the cardiac index and blood potassium level (r = 0.36; p = 0.03).

CONCLUSIONS: There was no significant difference between hemodynamic parameters in uncomplicated AWS and in delirium tremens. CI in patients with uncomplicated AWS and in those with DT decreased with age and with increase in the alcohol load. The vessel tone was inversely proportional to CI throughout the entire period of observation. With the development of delirium, a correlation was noted between a decrease in the level of energy metabolism and the probability for decompensation of systemic circulation. At the stage of reduction of delirium tremens, a correlation was noted between CI and the blood potassium level that reflected the exhaustion of the cardiovascular system and reduction of its compensatory capacities.

INTRODUCTION: The physical inactivity, hypoventilation, as well as chronic inflammation in obese patients aggravates their condition in various diseases. These features have become important with the advent of the COVID-19 pandemic, in which inflammation and platelet-activated coagulopathy are closely linked.

AIM: To study laboratory parameters of inflammation and platelet apoptosis in obese patients using various types of anticoagulant prophylaxis of venous thromboembolic complications with the underlying COVID-19.

MATERIALS AND METHODS: The study included 370 patients with COVID-19. Depending on the presence or absence of obesity and the type of parenteral anticoagulant, patients in our study were divided into groups: group 1 — non-obese + low molecular weight heparin (LMWH) (n = 114), group 2 — non-obese + unfractionated heparin (UFH) (n = 58), group 3 — obesity + LMWH (n = 76), group 4 — obesity + UFH (n = 66). The incidence of venous thromboembolic complications (VTEC), bleeding, general markers of the acute phase of inflammation, and specific markers of platelet apoptosis (phosphatidylserine and calreticulin) have been analyzed.

RESULTS: At the end of hospital treatment, a decrease in ferritin levels was noted in patients both with and without obesity receiving LMWH. The concentration of calreticulin was higher in patients taking LMWH (groups 1 and 3). Phosphatidylserine levels were high in patients receiving LMWH only if they were obese. In patients taking UFH compared to LMWH, a high incidence of pulmonary embolism (PE) without a source (13.6% of cases versus 2.6%, respectively, p = 0.029) and PE with a source in the lower extremities (9.1% of cases versus 0%, respectively, p = 0.018) was found. When using LMWH, a lower incidence of bleeding was observed compared to using UFH (5.3% of cases versus 16.7%, respectively, p = 0.056).

CONCLUSION: The levels of phosphatidylserine and calreticulin are higher in obese patients receiving LMWH. At the same time, patients in this group have a low incidence of VTEC and hemorrhagic complications compared to the group of patients taking UFH.

INTRODUCTION: Multiple sclerosis (MS) is a neurological demyelinating disease of the central nervous system manifested by pronounced heterogeneous symptoms. Peculiarities of the onset, progression rate, and severity of syndromes are different in different age groups. An increase in the frequency of exacerbations, high degree of disability of patients in different age groups evidence insufficient effectiveness of the conducted pathogenetic therapy. Due to a wide choice of multiple sclerosis disease modifying drugs (MSDMDs), it is important to study the clinical and neurological characteristics of patients with MS in different age groups with the aim of further developing an individual approach to treatment.

AIM: To study clinical and neurological features and effectiveness of pathogenetic therapy of MS in patients of different age groups.

MATERIALS AND METHODS: A prospective analysis of the data of neurological examination and results of magnetic resonance imaging of 100 patients of different age groups with relapsing-remitting MS, who received outpatient treatment in Kursk Regional Multidisciplinary Clinical Hospital, was conducted in the period of stable remission.

RESULTS: The leading syndromes in patients with relapsing-remitting course of MS were cerebellar (78%) and pyramidal (70%) syndromes, besides, dysfunction of the cranial nerves (71%) was also observed. A quantitative parameter of explicitness of pelvic disorder syndrome predominated in middle-aged and elderly patients compared to young ones (p < 0.001). Cognitive disorders were more often (14%) recorded in middle-aged and elderly patients (p < 0.001). The use of glatiramer acetate permitted to reduce the degree of disability in young subjects (p < 0.05); in patients of the middle age group, the most effective was a timely transition from interferon beta to ocrelizumab (p < 0.05). The use of first-line MSDMDs (interferon-beta) in elderly patients demonstrated low effectiveness (p < 0.05).

CONCLUSION: In middle-aged and elderly patients with equal timing of MS onset, the neurological deficit is more expressed than in young ones. First-line pathogenetic therapy, in particular, glatiramer acetate, is more effective in young patients, while patients of middle age are recommended an early transition to second-line MSDMDs.

INTRODUCTION: A modern standard for noninvasive diagnostics of the vascular system is duplex scanning. The knowledge of variability of vascular anatomy is essential for ultrasound doctors.

AIM: To clarify variants of the clinical anatomy of vessels of the popliteal region using duplex scanning and anatomical preparation.

MATERIALS AND METHODS: The work used data of duplex scanning of the arteries and veins of the lower extremities of patients without pathology of the vascular system of the lower extremities, who underwent examination of the vascular system: 200 patients aged from 18 to 92 years. As control, the data of anatomical preparation of 50 amputated lower extremities were taken, with preliminary filling the venous system with a blue synthetic gel.

RESULTS: In the course of anatomical preparation, two trunks of the popliteal vein were identified in the distal popliteal region in 86.0% of observations. A typical drain of the small saphenous vein with formation of the saphenopopliteal junction was encountered in 60.0% of cases. In duplex scanning, a high bifurcation of the popliteal artery was detected in 1.9% of observations. The two trunks of the popliteal vein in the distal part of the popliteal region were encountered in 82.4% of cases, and the medial trunk was almost always larger than the lateral one. The small saphenous vein drained into the popliteal vein in 63.0% of cases. In 7.2% of observations, it drained into one of the intramuscular veins. In 0.95% of observations, a perforator vein was identified in the popliteal region. The sural veins were identified in all the patients — two on the medial and lateral surface positioned at the sides of the two trunks of the sural arteries, forming a single trunk before confluence with the popliteal vein.

CONCLUSIONS: TThe study revealed the following anatomic variants of vessels of the popliteal region: two trunks of the popliteal vein below the knee joint cleft in 85.7% to 86.0% of observations; a high bifurcation of the popliteal artery in 1.9%; saphenopopliteal junction in 60.0% to 63.0%; perforator veins of the popliteal region in 0.95% of observations; upon that, the small saphenous vein does not form the saphenopopliteal junction.

INTRODUCTION: Covered esophageal self-expanding stents are often used to palliate dysphagia in patients with unresectable esophageal and gastric cardia cancer. Migration of an esophageal stent is a common occurrence in these patients. One of rare complications that can be caused by stent dislocation is intestinal obstruction.

The article describes a case of intestinal obstruction in result of migration of a fully covered nitinol esophageal stent. Patient K., 53 years old, was admitted to hospital in a severe condition with complaints of vomiting, abdominal pain and stool retention that had persisted for four days. The patient refused esophagogastroduodenoscopy. A plain abdominal X-ray did not reveal any free gas. In the mesogastrium, numerous pneumatized loops of small intestine with horizontal fluid levels were identified. For life indications, the patient, after preoperative preparation was taken to the emergency operating room; resection of the terminal part of small intestine was performed with placement of an ileostomy and gastrostomy. Taking into account difficulties of diagnosis (refusal of esophagogastroduodenoscopy by the patient and low informative value of X-ray examination), severity of the patient’s condition (due to a malignant neoplasm and intestinal obstruction), anatomical peculiarities (location of the esophageal stent 30 cm from the ileocecal angle, which would complicate potential application of enteroenteroanastomosis), the chosen tactics was to refuse application of enteroenteroanastomosis and exteriorize ileostomy and gastrostomy.

CONCLUSION: Acute intestinal obstruction is a threatening complication of migration of an esophageal stent. Patients with placed esophageal stents require careful monitoring, use of a sparing diet and additional methods of stent fixation, which will help reduce the frequency of stent migration and associated complications.

INTRODUCTION: Chronic intestinal ischemic syndrome (CIIS) is a pathology associated with chronic circulatory insufficiency in the visceral branches of the abdominal aorta. Duplex ultrasound can be used as the first imaging method to identify mesenteric artery stenosis. In general clinical practice, the diagnosis of CIIS is relatively rare. Expansion of application of percutaneous endovascular angioplasty and stenting of mesenteric arteries in recent years has significantly increased the effectiveness of treating patients with atherosclerotic lesion of the visceral arteries and CIIS.

AIM: To demonstrate a clinical case of use of X-ray endovascular technologies in CIIS in a patient of cardiology profile.

A clinical case of a patient with CIIS and severe decompensated polymorbidity is presented. Due to severity of the condition and impossibility of full examination for this reason, the patient was not included in the waiting list for heart transplantation despite the existence of indications for it. He was admitted to hospital for urgent indications. Ultrasound data revealed stenosis of the superior mesenteric artery. Balloon angioplasty and stenting of the superior mesenteric artery were successful. After discharge, the patient’s condition was satisfactory.

CONCLUSION: The case demonstrates that effective treatment of even one of many comorbid diseases in a severe polymorbidity patient can improve his general condition, reduce load on the cardiovascular system and reverse edematous-ascitic syndrome.

INTRODUCTION: Persistent post-COVID syndrome is the persistent physical, medical and cognitive sequelae of coronavirus disease 2019 (COVID-19), including persistent immunosuppression, pulmonary, cardiac and vascular fibrosis which lead to increased mortality and impair the quality of life of patients.

АIM: To analyze the completed foreign and domestic studies on the pathophysiology of transforming growth factor-β (TGF-β) in conditions of COVID-19, post-COVID syndrome, oncological and chronic inflammatory lung diseases.

Mast cells are among the main producers of inflammatory cytokines in COVID-19, their stimulation leads to the release of many proinflammatory cytokines, such as interleukin 1β, tumor necrosis factor α, interleukin 6, and also TGF-β. The basis of the pathogenesis of post-COVID syndrome is the overexpression of TGF-β leading to a prolonged state of immunosuppression and fibrosis. TGF-β acts as a tumor suppressor inhibiting proliferation and inducing apoptosis in the early stages of oncogenesis; plays an important role in most cellular biological processes leading to remodeling of the airway structures; is involved in epithelial changes, in subepithelial fibrosis, remodeling of smooth muscle of airways and in microvascular changes; induces resistance to glucocorticosteroids; stimulates the production of blood coagulation factor XII, thereby leading to development of potentially fatal complications, such as pulmonary embolism and ischemic stroke.

CONCLUSION: In this literature review, a structured analysis of a multicomponent role of TGF-β in the pathogenesis of post-COVID syndrome, pulmonary fibrosis in COVID-19, tumors of respiratory system, chronic obstructive pulmonary disease, bronchial asthma, is given. A possible use of TGF-β as a biomarker of severe and moderate degree of COVID-19 is substantiated.