Необходимость решения непростых задач по оказанию медицинской помощи (МП) больным критической ишемией нижних конечностей (КИНК) сохраняется. При выраженной коморбидности таких пациентов и, как следствие, ограниченных перспективах хирургической реконструкции сосудов, в качестве альтернативы прямой реваскуляризации НК особые надежды возлагаются на потенциал клеточной терапии (КлТ). Проанализированы результаты оказания МП 53 больным КИНК при использовании в комплексе их лечения биосубстанций, содержащих моноцитарные клетки костного мозга (МК КМ), с 2010 по 2014 г. Возраст пациентов колебался в пределах 49-85 лет. Сопутствующие заболевания констатированы у 100% больных, наиболее часто -патология сердца (62,3%). Сформированы две группы пациентов: больным I группы проводилась КлТ (КлТ-группа); во II -в мягкие ткани НК вводилось плацебо (Плцб-группа). На фоне комплексного лечения пациентов в течение 12 мес. НК удалось сохранить у 24 (67,7%) из 36 больных КИНК КлТ-группы. Ампутация НК (АНК) выполнена в 8 (22%) случаях. Умерли 4 (11%) пациента. В Плцб-группе больных КИНК АНК осуществлена 2 (11,8%) пациентам (сохранена в 15 (88,2%) случаях). В течение 5 лет наблюдения за больными КлТ-группы НК сохранены в 20 (56%) случаях (в 9 наблюдениях (25%) выполнены высокие АНК). Показатель частоты летальных исходов составил 19% (7 случаев). В ряде случаев клинически наблюдаемое улучшение течения КИНК не сопровождалось повышением лодыжечного АД, что позволяет судить о неоднозначности механизмов, обеспечивающих положительный эффект КлТ. Данные использования МК КМ при оказании МП пациентам с КИНК позволяют считать, что КлТэффективный компонент улучшения результатов лечения. Целесообразность дальнейшего целенаправленного изучения механизмов как позитивного, так и негативного воздействия МК КМ на организм больных КИНК несомненна. Ключевые слова: атеросклероз, критическая ишемия нижних конечностей, ангиография, клеточная терапия, стволовые кроветворные клетки.

No abstract

No abstract

Despite the successes in the examination and treatment of patients with prostate cancer, the problems associated with the organization of medical care for patients suffering from this disease remain. Defects in the verification of oncological diseases of the prostate often cause a decrease in parameters reflecting the quality and life expectancy of men. The data on the clinical case presented in the work demonstrate the difficulties of verifying a disease of a patient with prostate cancer, despite the involvement of many specialists of several medical institutions in the diagnostic process. With significant amounts of medical measures, the quality of the medical care provided at all stages can be considered inappropriate, primarily due to a violation of continuity in the management of the patient. Health care resources were used irrationally despite the fact that attempts were made to save the patient’s life at all levels and stages of medical care. Probably, defects in the provision of medical care could have been prevented by applying unified approaches in the diagnostic and treatment process using the advantages of information technology in modern computer databases of medical institutions, which make it possible to monitor the stages and volume of medical care provided to patients individually. In addition, the proper organization of medical care, as well as the targeted routing of patient flows should be provided not so much by clinicians as health managers. In the absence of opportunities in the treatment and prevention facilities, where patients are sometimes unplanned in urgent cases, the possibilities for carrying out diagnostic and treatment procedures, the healthcare organizers, together with the clinicians, must find reserves for referring patients to specialized medical organizations, in which examination and treatment of patients can be guaranteed. At the same time, the role, importance and effectiveness of the activities of health managers in the examination of the quality of medical care in each case should be evaluated separately.

General information about the activity of specialists of the regional vascular centers of St. Petersburg in 2011-2015 is presented. and on the private results of the work of the staff of the center of one of the city’s multidisciplinary hospitals with an assessment of the data on the cases of treatment of 403 patients with critical limb ischemia against the background of arterial lesions of atherosclerosis. Four groups of patients were identified: 278 patients who underwent open reconstruction of the arteries of the lower extremities; 51, who underwent endovascular revascularization; 15, who underwent hybrid surgical interventions. Revascularization was not performed in 55 patients. Among the open operations, loop endarterectomy from the aortoiliac and femoral-popliteal segments (190) and shunting arterial reconstructions (45) prevailed. In endovascular interventions, femoral-popliteal-tibial segments were predominantly corrected - 37 cases. Hybrid operations in 100% of cases are performed through accesses through the femoral arteries. In case of refusal of reconstruction due to the absence of an anatomic substrate for the reconstruction of the vessels, primary amputation of the lower limb (15), lumbar sympathectomy (14) were performed. In 30 cases, angiotropic therapy was performed. Complications of open surgical interventions in the early postoperative period were revealed in 21,6%, endovascular - in 15% of cases, hybrid operations were noted in 13,3% (in total91 complications in 70 patients). Thrombosis of the vascular reconstruction area (35%) and inadequacy of perfusion of limb tissues in permeable vessels (19,7%) prevailed in the structure of complications. There were no lethal outcomes. In general, the use of endovascular and hybrid reconstructions of the vascular bed in specialized divisions of medical organizations in patients with critical limb ischemia with multifocal atherosclerosis contributes to a significant reduction in the frequency of negative consequences of surgical revascularization of the lower extremities.