1СПб ГБУЗ "Городская многопрофильная больница № 2", Санкт-Петербург, Россия 2 Санкт-Петербургский Государственный Университет, Медицинский факультет, кафедра госпи-тальной терапии, Санкт-Петербург, Россия Амзаев Сергей Андреевич -аспирант кафедры госпитальной терапии медицинского факультета Санкт-Петербургского Государственного Университета, врач РЭДиЛ, городская многопрофильная больница №2, Санкт-Петербург, Россия email: Amzaev@yandex.ru, тел. 89217908000 Сергеев Алексей Сергеевич -врач РЭДиЛ, городская многопрофильная больница №2, Санкт-Петербург, Россия Сухов Валентин Константинович -д.м.н, профессор, врач РЭДиЛ, городская многопрофильная больница №2, Санкт-Петербург, Россия Шлойдо Евгений Антонович -к.м.н., зав. отделением РЭДиЛ, городская многопрофильная больница №2, Санкт-Петербург, Россия Обрезан Андрей Григорьевич -д.м.н, профессор, зав. кафедрой госпитальной терапии Санкт-Петербургского Госу-дарственного Университета; главный врач ММЦ «СОГАЗ», Санкт-Петербург, Россия В данной статье рассмотрены вопросы этиологии и патогенеза развития аорталь-ного стеноза, клиническая оценка степеней тяжести, основанная на выраженности симптомов при декомпенсации аортального порока и эхокардиографических пара-метрах, и современные методы коррекции аортального стеноза. Общепризнанным «золотым стандартом» в лечении аортального стеноза является протезирование кла-пана. Однако операция протезирования аортального клапана у пациентов старшей возрастной группы с различной сопутствующей патологией сопряжена с высоким уровнем периоперационных осложнений. Альтернативными способами лечения аортального стеноза являются метод баллонной вальвулопластики и транскатетерная имплантация аортального клапана. Анализ собственного опыта применения данных малоинвазивных методов коррекции критического аортального стеноза убедительно демонстрирует снижение периоперационных рисков у пациентов старшей возрастной группы с сопутствующей патологией и убеждает в необходимости госпитализации ко-морбидных возрастных пациентов со значительными степенями стеноза аортального клапана и продвинутыми степенями сердечной недостаточности в специализирован-ных центрах, где возможен комплексный подход в лечении данной патологии, кото-рый приводит к улучшению результатов лечения и благоприятному прогнозу у этой сложной категории пациентов.Ключевые слова: аортального клапана стеноз, факторы риска, баллонная дила-тация, аортального клапана транскатетерная имплантация, коморбидность.
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.
Clinical aspects, risk factors, results of selective coronary angiography, features of DNA-polymorphism (I/D polymorphism of gene ACE, isoalleles polymorphism gene APOE, SsTI polymorphism gene АРОСЗ, С677Т polymorphism of gene MTHFR, 4a/4b, G894T and T786C polymorphisms eNOs) in 89 women with a various degree of a coronary obstruction. In patients with sings of coronary artery atherosclerosis, familial history i heart disease was observed in most cases (greater degree on a line of mother). The obtained data show the reliable role of allele T, genotype CT gene MTHFRand gene-gene interaction of ACE and MTHFR genes (DD и СС, DD и СТ) in development of i heart disease.
The aim of the study was to evaluate the outcomes of health care in the setting of a regional vascular centre of a multidisciplinary hospital in patients with critical lower limb ischemia based on the data of preoperative arterial hypertension of the leg circulatory bed. Materials and methods. General data on the organisational effectiveness of regional vascular centres in the second largest Russian city, Saint Petersburg, were analysed. The work of a large multidisciplinary medical organisation of the city, City Multidisciplinary Hospital No. 2, was studied in detail, whose regional vascular centre examined and treated 295 men and 88 women with pathology of the lower limb arteries in 2013-2015. The patients underwent the following surgeries: open vascular reconstruction-282, endovascular revascularisation-47, and hybrid surgical interventions were performed in 15 patients. In 55 cases, lower limb revascularisation was refused due to lack of opportunities for vascular bed reconstruction or because of irreversible changes in the tissues of the lower limbs. Results. Application of the options of lower limb artery angiography preoperatively allowed to reliably estimate the degree of damage to the vascular bed, and make a reasoned choice between leg artery revascularisation methods. This technique proved to be most effective in patients with critical lower limb ischemia with severe comorbidity. Overall, the incidence of complications of open surgical interventions in vascular bed in the early postoperative period was 21.6%, and of endovascular and hybrid surgeries-15% and 13.3%, respectively. No cases of deaths were reported. Conclusions. Endovascular and hybrid surgical interventions in obliterating diseases of the lower limb arteries provides a significant reduction in the incidence of intra-and postoperative complications in patients with multifocal atherosclerosis, and their combination with the use of less traumatic "open" surgical interventions (semiclosed loop endarterectomy) offers new opportunities in the therapy of patients with critical lower limb ischemia.
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