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Aim. To specify the indications for in situ femoropopliteal (tibial) bypass, to study complications rate immediately after, within 1 and 2 years of the surgery. Methods. The study group included 33 patients with symptoms of critical lower limb ischemia, who underwent femoral-popliteal or femoral-tibial bypass. 4 (12.1%) cases of type C and 29 (87.9%) cases of type D arterial bed lesions according to TASC II classification were revealed after investigation. Patients were followed up for 2 years period. Shunt thrombosis rate, condition of the trophic ulcers, chronic arterial ischemia stage before and after the surgery, mortality, lower limb amputation were measured outcomes. Results. Repeated reconstructions rate for primary shunt thrombosis immediately after surgery was 30.3±8.0%. Shunt thrombosis (secondary) occurred in only three (9.1±5.0%) patients. The main causes which led to the shunt thrombosis during or at the 1st day after the surgery, were absence of intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries. Trophic defects healing was observed in 3 (30.0±14.5%) of 10 patients with ulcers immediately after surgery and in all cases (100.0%) by the end of 1 year follow-up. The total number of high-level amputations within 2 years was 25.8±7.9%, the overall mortality rate within 2 years was 6.1±4.2%. Femoral-popliteal or femoral-tibial bypass surgery allowed to preserve the limb in 74.2% of patients within 2 years of follow-up. Bypass patency was preserved in 41.7% of patients out of 24 in situ bypass surgeries for the follow-up time. In our opinion critical limb ischemia with significant and extended arterial bed lesions of D and C types (according to TASC II score) is one of the indications for in situ femoropopliteal (tibial) bypass as for the surgery of the first choice. Endovascular treatment is also impossible for this type of lesion, as alternative surgeries using reversed autovein and synthetic explant do not meet all the requirements for an extended bypass. Conclusion. The lack of adequate intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries may be the causes of early postoperative shunt thrombosis; despite the low femoropopliteal (tibial) bypass patency rate in patients with critical ischemia, the surgery was recognized as efficient as it allowed to preserve the limbs in 74.2% of patients.

Цель исследования-анализ эффективности оригинального способа пластики тибиоперонеального ствола при аутовенозном бедренно-подколенном шунтировании. Материал и методы. С 2016 по 2017 г. прооперированы 18 пациентов, которым выполнено бедренно-подколенное шунтирование (БПШ) реверсированной аутовеной с пластикой тибиоперонеального ствола. Возраст больных составил от 54 лет до 81 года (средний возраст 70,3±12,2 года). Анализировались частота тромбозов шунта в послеоперационном периоде, динамика хронической артериальной недостаточности в до-и послеоперационном периодах, летальность, количество ампутаций нижней конечности. Результаты. Согласно классификации TASС II отмечались следующие варианты поражения бедренно-подколенного сегмента: тип C наблюдался в 7 (38,9%) случаях, тип D-в 11 (61,1%). Из общего числа исследуемых острая артериальная недостаточность IБ-IIA стадии с последующей постэмболической окклюзией артерий нижних конечностей отмечена в 5 (27,7%) случаях. Хроническая артериальная недостаточность III стадии наблюдалась у 6 (33,3%) пациентов. Артериальная недостаточность IV стадии на фоне распространенного атеросклероза артерий нижних конечностей зафиксирована в 7 (38,8%) случаях. Первичная проходимость шунтов при выписке из стационара составляла 100%, к концу 1-го года наблюдения-83,4%. На стационарном этапе лечения и в отдаленном периоде до 1 года летальных случаев не наблюдалось. В 3 (16,6%) случаях на 1-м году наблюдения отмечался тромбоз шунта с рецидивом клиники критической ишемии, несмотря на проводимое лечение. Выводы. Клиническое улучшение (купирование болевого синдрома, трофических расстройств, полное восстановление функции конечности) и доля сохраненных конечностей к концу первого года наблюдения составляют 83,4%. Ключевые слова: бедренно-подколенное шунтирование, аутовенозное шунтирование, критическая ишемия, хроническая артериальная недостаточность, пластика тибиоперонеального ствола.

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Aim. To define the indications and to evaluate the effectiveness of various surgical treatment methods in patients with arterial stenosis and occlusion due to atherosclerotic vascular disease of lower extremities as a complication of diabetes mellitus. Methods. Results of surgical treatment of 52 randomly assigned patients who underwent surgeries due to peripheral vascular disease as a complication of diabetes mellitus (type 2 - 51 patients, type 1 - 1 patient) were analyzed. The following surgeries were performed: arterial reconstructive surgery - 24 (46.2%) patients (group 1), balloon catheter angioplasty and stenting - 12 (23.1%) patients (group 2), indirect revascularization surgery (revascularising osteotrepanation, endovascular prostaglandin E therapy) - 16 (30.7%) patients (group 3). Following parameters were assessed: decrease of ischemic rest pain, arterial insufficiency stage, hospitalization terms, healing of foot ulcers, mortality rate, and amputation rate. The longest foot ulcers healing terms [only in 5 patients (31.2%) at first year] were registered in the third group. 1 death was registered each in the first and in second groups (mortality rate 4.2 and 8.3% respectively), no deaths were registered in group 3. The results of trophic ulcers treatment in the patients from the third group were poor. It is tactically appropriate to prefer endovascular surgeries to open surgeries as far as in this case there is no need for local and general anesthesia allowing to decrease the number of complications and the length of rehabilitation together with comparable results. Primary open arterial reconstructive surgeries are possible in patients with diabetes mellitus as a next step after endovascular surgery or when endovascular surgery can not be done. Conclusion. Similar instant and long-term results were found after direct comparison of bypass and endovascular surgeries, allowing to recommend these surgeries in patients with peripheral vascular disease as a complication of diabetes mellitus.