ЦЕЛЬ: исследовать информативность комбинации разных неинвазивных оптических подходов в диа- гностике заболеваний артерий нижних конечностей (ЗАНК) у пациентов с сахарным диабетом (СД). МАТЕРИАЛЫ И МЕТОДЫ: проведено обсервационное исследование на 54 пациентах с СД 2 типа (39 конечностей со стенозами/окклюзией, 69 – без стенозов). Наличие гемодинамически значимых стено- зов магистральных артерий нижних конечностей (более 50%) оценивали по результатам ультразвукового дуплексного сканирования (УЗДС) как референтного метода. Всем пациентам оценивали показатели гемо- динамики при помощи комплексной технологии, реализующей методы некогерентной оптической флук- туационной флоуметрии (НОФФ), фотоплетизмографии и тонометрической осциллометрии. Технология позволяет одновременно оценивать перфузию тканей стопы в ходе теплового теста, перфузию тканей руки, скорость пульсовой волны, форму пульсовой волны. Дополнительно пациентам оценивали лодыжечно- плечевой индекс (ЛПИ) как стандартный скрининговый метод выявления ЗАНК. РЕЗУЛЬТАТЫ: применение показателей перфузии на стопе в ходе теплового теста, измеренных методом НОФФ, позволяет с чувствительностью 79,5% и специфичностью 88,4% выявлять конечности с гемоди- намически значимыми стенозами (AUROC 0,884, CI: 0,817-0,953). При комбинации показателей перфузии на руке и ноге, формы пульсовой волны и скорости пульсовой волны при помощи модели множественной логистической регрессии, чувствительность модели в выявлении конечностей со стенозами значимо воз- растает до 88,6%, а специфичность – до 92,8 % (AUROC 0.928, CI: 0.8742-0.9809). При этом чувствительность и специфичность ЛПИ, как стандартного метода выявления ЗАНК значимо ниже, и составляет 48,7% и 87,0 % соответственно. ВЫВОДЫ: комбинация нескольких параметров гемодинамики, оцениваемых одномоментно при помо- щи комплексной оптической технологии, позволяет добиться высокой чувствительности и специфичности в выявлении ЗАНК у пациентов с СД (88,6% и 92,8% соответственно). Техническая простота измерения (10 минутное измерение с низкой оператор-зависимостью) позволяет рассматривать подход как перспектив- ный для скринингового выявления ЗАНК.

55 НОВЫЙ МЕТОД НЕКОГЕРЕНТНОЙ ОПТИЧЕСКОЙ ФЛУКТУАЦИОННОЙ ФЛОУМЕТРИИ В ОЦЕНКЕ ПЕРФУЗИИ ТКАНЕЙ СТОПЫ У ПАЦИЕНТОВ С САХАРНЫМ ДИАБЕТОМГлазкова П .А ., Загаров

ВОЗМОЖНОСТИ КТ-АНГИОГРАФИИ В ОЦЕНКЕ АНЕВРИЗМ ЭКСТРАКРАНИАЛЬНЫХ ОТДЕЛОВ СОННЫХ АРТЕРИЙ (СЕРИЯ РЕДКИХ НАБЛЮДЕНИЙ)Вишнякова М.В.(мл), Лунина С.М., Вишнякова М.В., Ларьков Р

Background: The main cause of mortality in patients with atherosclerosis of aorta and peripheral arteries of the lower extremities is ischemic heart disease. The presence of peripheral artery atherosclerosis suggests a high probability of simultaneous coronary involvement. To reduce the risk of cardiac complications, these patients are offered myocardial revascularization as the first step of the intervention; however, the choice of a conduit for coronary artery bypass in these patients remains challenging.Case report: A 58-year old man with combined coronary artery stenoses, high occlusion of the aorta and common iliac arteries underwent autoarterial myocardial revascularization with the right internal thoracic artery (ITA) and left radial artery ("off pump”). In the early postoperative period, significant progression of the right leg ischemia was observed, related to partitioning of the main collateral flow between the right ITA and the inferior epigastric artery, that had contributed to blood supply to the right lower extremity. Taking into account the lack of efficacy of medical treatment and progression of the leg ischemia, at day 4 postoperatively the patient underwent resection of the infrarenal aorta with aortobifemoral bypass grafting and restoration of blood supply to the lower extremities and resolution of ischemia.Conclusion: ITA has been recognized as the conduit of choice for surgical treatment of ischemic heart disease; however, its use may result in significant progression of ischemia. When choosing a conduit, ITA at the side of less ischemic lower extremity is preferred. ITA imaging by computed tomography-angiography or by selective ITA angiography can be helpful for assessment of the ITA significance at the side of less ischemic leg. Also, the appearance of retrograde flow in the inferior epigastric artery at Doppler ultrasound examination can be a conditional valuable criterion.

Background: At present, efficacy of carotid endarterectomy for prevention of cerebrovascular accidents has been convincingly proven. Its results in patients with a history of an ischemic stroke depend on multiple factors.Aim: To study results of reconstructive interventions on internal carotid arteries in patients with post-stroke cerebral cysts.Materials and methods: We analyzed data from 210 patients who had undergone an intervention (159 men and 51 women, aged 61 ± 2.7 years) with occluding lesions of the internal carotid artery and a history of an ischemic stroke. Depending on the size of a post-stroke lesion, patients were divided into 5 groups: patients from group 1 had a lesion of more than 5 cm in diameter, from group 2, from 2 to 5 cm, from group 3, ≤ 2 cm, patients from group 4 had a lacunar cysts and patients from group 5 had no focal lesions.Results: A clear positive correlation between the size of a post-stroke cyst and the degree of hemodynamic abnormalities in internal carotid arteries was found. The most prominent asymmetry of blood flow in the middle cerebral artery (on average, 34.1%) was seen in patients from the group 1. Patients from the group 1 more often had low and critical brain tolerance to ischemia (42.9%). In patients with large post-stroke cysts (group 1) mean Barthell index was 69 ± 8.1, and NIHSS score 8.2 ± 1.6. In patients from other groups neurological deficiency was less pronounced: 80 ± 6.8 and 7.6 ± 1.9 in the group 2, 82 ± 5.7 and 4.1 ± 1.3 in the group 3, 94 ± 4.6 and 3.2 ± 1 in the groups 4 and 5. The differences between groups in the rates of postoperative complications were not statistically significant (p > 0.5). However, signs of hyperperfusion without any clinical manifestations were more often observed in patients from the group 1 (19%). Assessment of changes in neurological status at 1 year after the intervention, depending on the size of post-stroke lesions, showed that in patients with large cysts the regression of neurological deficiency was less obvious, than in other groups (NIHSS 7.5 ± 1.7, Barthell index 76 ± 7.7). The best restoration of impaired neurological functions was seen in patients with small cysts (NIHSS 2.2 ± 0.7, Barthell index 91 ± 3.4).Conclusion: In patients with large and intermediate post-stroke cerebral cysts surgery is associated with a higher complication rate, and, first of all, of hyperperfusion syndrome. However, the risk of these complications is significantly smaller than the probability of repeated acute cerebrovascular accidents.

Background: Stenoses of the brachiocephalic arteries (BCA) are ones of the main causes of ischemic defects of cerebral circulation. From the end of the former century to the current time, the surgical cerebral revascularization in steno-occlusive BCA disturbances occupies the topical place in prevention of acute brain circulation defects. Carotid endarterectomy (CEAE) remains till now a basic method of surgical revascularization. As a result of chronic hypoperfusion, autoregulation of the cerebral circulation can be disturbed with a persistent capillary dilatation which enables development of hyperperfusion syndrome after surgical intervention. Aim: A quantitative assessment of the cerebral tissue perfusion disturbances depending on the variants of the brachiocephalic vessels lesions before and after surgical reconstructions as well as revealing possible prerequisites for hyperperfusion syndrome development during preoperative multislice computed tomography (MSCT) perfusion. Materials and methods: The results of examination and treatment of 65 patients (mean age 64.2±5.0 years) with chronic cerebrovascular IV stage insufficiency were analyzed as well as the hemodynamically significant lesion of the inner carotid arteries. CEAE was planned for all patients. All patients underwent cerebral MSCT angiography and MSCT perfusion in preoperative and early postoperative periods. Results: The majority of patients in preoperative period showed decrease of perfusion parameters at the side of the most expressed defects. The mean circulation deficiency varied from 12 to 15%. Improvement of circulation at the side of surgical intervention formed, on the average, about 12%. The best outcome was noted in patients with bilateral stenoses of the inner carotid arteries (ICA). In one case, in critical unilateral ICA stenosis in preoperative period, MSCT perfusion demonstrated persisting dilatation of the small cerebral arteries of the disturbed hemisphere which led to autoregulation defects of these arteries with a high risk of hyperperfusion syndrome development. On the second day of the postoperative period, the said hyperperfusion syndrome developed but was successfully arrested using hypotensive therapy. Conclusion: CEAE provides circulation improvement in patients with ischemic stroke. MSCT perfusion favors circulation improvement in ischemic stroke patients. MSCT perfusion allows revealing patients with high risk of hyperperfusion syndrome development in postoperative period.

Background. An effective treatment for renal cell carcinoma complicated by tumor thrombus (TT) is nephrectomy with thrombectomy (NETE) from the inferior vena cava (IVC), which is associated with massive blood loss, high morbidity and mortality. The study aims to evaluate the infusion-transfusion protocol (ITP) for NETE from the IVC without extracorporeal circulation. Materials and methods. The observational single-center study included 682 patients who were operated for NETE for renal cell carcinoma with TT. Patients were divided into 3 groups depending on the level of TT according to the Mayo classification. The InfraHepatic (InH) group included patients with TT levels I and II, the RetroHepatic (RH) group included patients with TT level III, and the SupraDiaphragmatic (SD) group included patients with TT level IV. Own concept of moderately advanced infusion in the amount of 130–140% of all losses were introduced. Qualitative and quantitative composition of ITP, frequency of use of sympathomimetics, complications and mortality were assessed. Results. The rate of massive blood loss was 46.9% in the InH group, 74.7% in the RH group, and 86.3% in the SD group. ITP was characterized a significant increase in the absolute values of all infusion media, a decrease the proportion of crystalloids and colloids, an increase the proportion fresh frozen plasma, donated erythrocytes, and proportion of auto-erythrocytes between groups. The frequency of using intraoperative cell salvage in the InH group was 39.6%, in the RH – 67.7%, in the SD – 90.7%. The greatest hemodynamic shifts were recorded in the SD group. The frequency of postoperative complications was 24.3%, and hospital mortality was 7% with accordance to the ITP, adequate hemodynamic and laboratory monitoring in NETE. Low mortality due to hemorrhagic shock in our study (0.15%) emphasizes the effectiveness of the presented ITP. Conclusion. The obtained data demonstrate the results of NETE as comparable with those presented in the available literature.