Lower Leg Arteries Research Articles

Outcomes of Proximal Hybrid Arterial Reconstruction in Combination with Simultaneous Amputation in Dry Atherosclerotic Gangrene of Toes

INTRODUCTION: When treating atherosclerotic gangrene of the lower limb (LL), the surgeon faces the questions about the reasonability of vascular reconstruction and the optimal timing of amputation after surgery on the LL arteries. The answer to these questions is given by assessing the state of the microvasculature of the operated limb. With sufficient development of the microvasculature and good collateral circulation, it is possible to perform a simultaneous amputation after proximal reconstruction. In this situation, a clear demarcation of the zone of necrosis and reversible ischemia is required, which can be realized by the method of ultraviolet luminescence spectroscopy. AIM: To analyze the results of hybrid reconstructions on the LL arteries with multilevel diffuse atherosclerotic lesions and dry gangrene of toes (DGT). MATERIALS AND METHODS: A prospective, controlled, non-randomized study included 29 patients suffering from critical ischemia of the lower limbs and having DGT, who were operated on in the amount of hybrid arterial reconstruction. The patients were divided into two groups: patients of group 1 (n = 14) underwent restoration of the main blood flow at the level of the iliofemoral arterial segment using a hybrid method, with simultaneous minor amputation of LL at various levels; patients of group 2 (control group, n = 15) underwent a simultaneous proximal and distal hybrid operation, providing main blood flow through at least one of the lower leg arteries, followed by a minor amputation of the lower leg at various levels over the next 4–5 days. RESULTS: There were no statistically significant differences in the groups in the degree of decrease in luminescence intensity after vascular surgery. A histological examination of intraoperative preparations of DGT revealed necrosis of the cellular microenvironment at luminescence amplitude (1.0 ± 0.05) × 105 photons at 410 nm frequency. At luminescence amplitude not exceeding this level, signs of necrobiosis were noted. Luminescence level of ≥ 1.0 × 105 photons was used as the amputation boundary. In the case of an uncomplicated vascular stage of the operation, a comparable decrease in the conventional amputation boundary was noted in the study groups. In the early postoperative period, in patients of group 1, the level of inflammation markers, average number of bed-days, and the number of thrombotic complications were lower than in the control group (p 0.05). A strong correlation was recorded between the morphological signs of the acute phase of inflammation and the intensity of chemiluminescence (r = 0.7, p 0.005). CONCLUSION: In patients with DGT, at a luminescence amplitude on the lower leg and foot not exceeding 1.0 × 105 photons at 410 nm frequency and 0.7 × 105 photons at 450 nm frequency, an effective treatment method is restoration of the main blood flow in the iliofemoral segment using a hybrid method with simultaneous minor amputation at various levels of the foot. This luminescence level is the conventional boundary between necrotic changes and reversible ischemia (necrobiosis) of the soft tissues of the LL.

ENDOVASCULAR ANGIOPLASTY FOR REPEATED REVASCULARIZATION OF THE ARTERIAL BED IN PATIENTS WITH RECURRENT CHRONIC ARTERIAL INSUFFICIENCY

Aim. To improve the results of repeated reconstruction of the great vessels in case of relapse of chronic arterial insufficiency by differentiated use of popliteal tibial autovenous bypass grafting and endovascular angioplasty for revascularization of the arteries of the leg. Materials and methods. The long-term results of surgical treatment of 522 patients were examined, including 353 patients with bilateral atherosclerotic occlusion of the aortic-femoral zone and 159 patients with unilateral occlusion of the ileo-femoral segment. At the primary surgical intervention, 98 patients were diagnosed with chronic arterial insufficiency (CAI) of stage II B, in 228 – CAI of stage III, in 196 – chronic critical ischemia of the lower extremities, stage III – IV. In the long-term postoperative period, 146 (27.97 %) late complications were diagnosed, of which 78 (56.1 %) had a relapse of chronic arterial insufficiency. In 36 patients, CAI stage II B was established, and in 42 – CAI stage III. Patients were re-operated in the period of 5.4 ± 1.9 years after primary revascularization. All men were 64.4 ± 3.1 years old. Results. The multilevel atherosclerotic lesions of the reconstructed arterial bed, cicatricial changes after the initial surgical intervention, progressive atherosclerotic lesions of the outflow tract required multi-story shunting operations. The success of shunting surgery depends on sufficient revascularization of the outflow paths – the arterial bed of the ankle segment. Revascularization of the distal arterial bed was achieved using popliteal-tibial autovenous bypass grafting (19 cases) and endovascular angioplasty (30 observations). To reduce peripheral vascular resistance and increase the volume of the peripheral vascular bed in 19 (63.3%) cases, endovascular balloon angioplasty of two tibial arteries was performed simultaneously. The postoperative period in 10 (12.8%) patients was complicated by the development of thrombosis of the reconstruction segment. In 7 cases, thrombosis of the reconstruction segment was eliminated. The using of popliteal-tibial autogenous bypass grafting and endovascular angioplasty during revascularization of the ankle segment provided satisfactory results in repeated reconstructive operations in 87.2 % of cases. Conclusions. For the revascularization of the lower leg arteries, the use of popliteal autovenous shunting and endovascular angioplasty provides 87.2% satisfactory results in repeated reconstructive operations for chronic arterial insufficiency relapse.

Outpatient regenerative therapy of a chronic diabetic foot ulcer with exposed bone surface

BACKGROUND: Treatment of deep chronic wounds with the bone tissue involvement against the background of lower limb atherosclerosis and diabetic foot syndrome does not fit any reasonable hospital stay duration and at the same time has no effective outpatient methods. Therapy with conditioned medium derived from human mesenchymal stem cells (CM-MSC) may be a solution for this problem. CLINICAL CASE DESCRIPTION: Patient F., 77-year-old, arrived for an outpatient treatment of local necrosis in the area of the 1st toe of the left foot in April, 2022. The main diagnosis: Peripheral arterial disease of the lower extremities. Multifocal atherosclerosis. Occlusion of the superficial femoral and popliteal arteries, diffuse lesions of the lower leg arteries on the left. Chronic arterial insufficiency of the 4th degree. Attempts of revascularisation of the left lower limb. Limited gangrene (Wagner IV) of the 1st toe of the left foot. Associated diseases: insulin-dependent type 2 diabetes mellitus (for more than 30 years). Diabetic polyneuropathy. Diabetic foot syndrome, neurotrophic form. Local treatment was performed by the microsurgical debridement of the affected surface in combination with the method of multilayered dressings, according to the previously patented technology. The microsurgical treatment of the bone surface in the wound area was carried out with the use of CM-MSC. Positive dynamics in the form of a partial closure of the bone fragment with soft tissue was observed on the sixth month of therapy. The complete closure of the open bone fragment was observed in 12 months from the beginning of the outpatient treatment. CONCLUSION: The developed method of treatment using CM-MSC can be effective for chronic wounds with open bone surfaces.

Determination of predictors of adverse outcome in patients with acute limb ischemia with a new coronavirus infection in the acute phase of the disease

Relevance. At the moment, the study relevance is determined by extremely insufficient coverage of this issue, which in turn directly affects managing patients with this pathology. Study objectives: to analyze outcomes of surgical treatment of patients with acute ischemia of lower limbs in connection with the new coronavirus infection and in­hospital mortality; to identify predictors of adverse outcomes; to construct a prognostic model for patients with acute limb ischemia and severe acute respiratory syndrome­related coronavirus­2 (hereinafter – SARS-­Cov-­2). Material and methods. Study design: single­center, retrospective study. We retrospectively analyzed 47 patients with acute limb ischemia (ALI) on confirmed SARS-Cov­-2 for the period from September 2020 to April 2022. In this study, we analyzed the mean age of patients, laboratory tests results, comorbidities, ischemia grade, imaging data, choice of treatment strategy, and in­hospital mortality. Statistical analysis revealed a correlation between clinical outcomes in patients with ALI and SARS­-Cov-­2 severity. Results. The mean age of the patients was 71.1  6.3 years. Acute ischemia of the upper limb was present in 3 of them. The mean concentration of D­dimer was 4,645 ng/mL. The mean level of ferritin was 969.1 µg/L. SARS-­CoV­-2 was confirmed in 100% of patients. The distribution of ALI grades (according to I.I. Zatevakhin's clasification) was as follows: 1 – 8.5% (n = 4); 2A ­ 44% (n = 21); 2B – 39% (n = 18); 3A – 8.5% (n = 4); 78.5% of patients received anticoagulants. Patients with comorbidities were distributed as follows: diabetes mellitus – 38.7%; hypertension – 85.3%; history of cerebrovascular disorders – 64.7%; AFib arrhythmias – 42.4%. The severity of viral pneumonia according to CT: CT1 – 12% (n = 6), CT2 – 19% (n = 9), CT3 – 29% (n = 14), CT4 – 21% (n = 10), CT was not performed – 19% (n = 8 because of the condition severity). Patients were grouped by intervention type: selective thrombolysis – 9%, surgical thrombectomy – 10%, endovascular interventions – 63%, hybrid interventions – 18%. Clinical outcomes (all­cause mortality, major cardiovascular events, repeat revascularization) were retrospectively evaluated. Using regression analysis, we found a correlation between the end­point and the severity of the underlying disease, assessed predictors of adverse outcomes, and constructed a prognostic model. Complications were also evaluated; according to our data, three patients had early thrombosis in their reconstruction zones and two patients had technical failures of revascularization of their lower leg and foot arteries. In­hospital mortality was 65.3%. Conclusion. Our prognostic model allowed to find a correlation between clinical and laboratory data and the end­point. Keywords: revascularization, SARS-­Cov­-2, thrombosis, acute ischemia, thrombotic events, endovascular interventions

Multidisciplinary approach in the treatment of patients with diabetic foot syndrome. Experience of Almazov National Medical Research Centrе

Objective Evaluate the effectiveness of the multidisciplinary specialists team in Almazov National Medical Research Centrе to the treatment of patients with the neuroischemic form of diabetic foot syndrome in a multi-field hospital.Materials and methods We made retrospective analysis of the multidisciplinary approach to the treatment of patients with a neuroischemic form of diabetic foot syndrome who were hospitalized to Almazov National Medical Research Centrе during the period from January 2018 to July 2020 (inclusively). The patients were treated in the clinic of the Almazov National Medical Research Centrе during one hospitalization period. The investigation includes patients over 18 years old with a diabetes mellitus who were performed revascularization at the vascular surgery clinic Almazov National Medical Research Centrе. Patients with a secondary diabetes mellitus, immunosuppressive therapy were excluded from the study. 51 patients with neuroischemic form of diabetic foot syndrome were specifically selected for analysis. We gathered all information about them till August 2022. So, the period of observation was from 2 years 8 months (32 months) to 4 years 8 months (56 months). The mediana time was 44 months (3.67 years). All inclusive patients had a diabetic ulcer on the foot. The outcomes of this study were the healing or non-healing of diabetic foot ulcers, major amputation or death (from all causes).Results Successful healing of ulcers or postoperative wounds at the time of contact with the patient or his relatives, was with 45 patients (88.3 %). In more than half of the patients (56.86 %) healing of ulcers and wounds was occurred in the 3 months after operation.70.59 % (n = 36) patients were performed orthopedic organ-preserving reconstructions on the feet in the hospital. 6 patients (11.7 %) were performed initially revascularization according to the “less affected pathway” principle which didn’t heal the ulcers in the postoperative period and leaded to repeated surgery to restore blood flow according to the angiosomal principle. For 9 patients (17.64 %) it was required to perform repeated orthopedic intervention on the foot during the current hospitalization. The causes of complications were: stent thrombosis (n=3), intimal dissections (n = 2) and distal embolism (n = 1). The reasons for repeated orthopedic surgery were marginal necrosis in the postoperative wounds. Optimal revascularization wasn’t achieved with 10 (19.6 %) patients. Despite this in 4 (7.84 %) cases ulcers was healed. In two cases, 3.92 % (n = 2) suboptimal revascularization was associated with the lack of technical possibility in revascularization of the lower leg arteries with satisfactory revascularization of the femoral-popliteal segment. Indirect revascularization with no effect was performed in 4 cases (7.84 %). 6 major amputations (11.7 %) were performed during the observation period, 1 major amputation during the current hospitalization and 5 in the long-term period. The Kaplan-Mayer three-year survival rate was 80 %.Conclusion The analysis of the results of a multidisciplinary approach to the treatment of patients with diabetic foot syndrome demonstrated an improvement in the preservation of the limbs, reduced of bone-plastic reconstructions, reduсtion of hospitalization time and improving the lives of patients.

Evaluation of Lower Leg Arteries and Fibular Perforators before Microsurgical Fibular Transfer Using Noncontrast-Enhanced Quiescent-Interval Slice-Selective (QISS) Magnetic Resonance Angiography.

(1) Background: Preoperative imaging of the lower leg arteries is essential for planning fibular grafting. The aim of this study was to evaluate the feasibility and clinical value of non-contrast-enhanced (CE) Quiescent-Interval Slice-Selective (QISS)-magnetic resonance angiography (MRA) for reliably visualizing the anatomy and patency of the lower leg arteries and for preoperatively determining the presence, number, and location of fibular perforators. (2) Methods: The anatomy and stenoses of the lower leg arteries and the presence, number, and location of fibular perforators were determined in fifty patients with oral and maxillofacial tumors. Postoperative outcomes of patients after fibula grafting were correlated with preoperative imaging, demographic, and clinical parameters. (3) Results: A regular three-vessel supply was present in 87% of the 100 legs. QISS-MRA was able to accurately assign the branching pattern in patients with aberrant anatomy. Fibular perforators were found in 87% of legs. More than 94% of the lower leg arteries had no relevant stenoses. Fibular grafting was performed in 50% of patients with a 92% success rate. (4) Conclusions: QISS-MRA has the potential to be used as a preoperative non-CE MRA technique for the diagnosis and detection of anatomic variants of lower leg arteries and their pathologies, as well as for the assessment of fibular perforators.

Pulsatile Intravascular Lithotripsy: A Novel Mechanism for Peripheral Artery Calcium Fragmentation and Luminal Expansion

ObjectiveTo assess the feasibility and treatment effect of pulsatile intravascular lithotripsy (PIVL) on calcified lesions in a cadaveric model of peripheral artery disease. BackgroundPIVL represents a novel potential approach to intravascular lithotripsy for the treatment of vascular calcification. MethodsIn this preclinical device-feasibility study, technical success, calcium morphology and luminal expansion before and after PIVL treatment were evaluated in surgically isolated, perfused atherosclerotic lower-leg arteries and in perfused whole cadaveric lower legs. Analytical methods included micro-computed tomography (μCT), intravascular optical coherence tomography, digital subtraction angiography, and quantitative coronary analysis. ResultsTreatment delivery was successful in all whole-leg specimens (N = 6; mean age 74.2, 66 % female) and in the 8 excised vessels with diameter appropriate to the PIVL balloon (2 vessels exceeding diameter specifications were excluded). There were no vessel perforations. After PIVL, excised vessels showed extensive evidence of new, full-thickness fractures in lesions with calcium arc exceeding 152° and with calcium wall thickness between 0.24 mm and 1.42 mm. PIVL fractures were observed in intimal nodules, sheets, shingles, and medial plates. Vessels within whole-leg specimens also showed full-thickness fracturing and a mean of 1.9 ± 0.9 mm in acute luminal gain, 101.6 ± 99.5 % gain in total minimum cross-sectional area, and a 31.7 ± 13.4 % relative reduction in stenosis (P < 0.001 for all analyses). ConclusionsIn a cadaveric model, PIVL treatment was technically feasible, fractured both circumferential and eccentric calcium lesions, and resulted in acute luminal gain. A clinical feasibility study of PIVL is currently enrolling.

Компьютерная томография и ультразвуковое исследование в диагностики некротизирующего фасциита

The purpose — to demonstrate the capabilities of computed tomography and ultrasound in the diagnosis and treatment planning of a patient with a rare case of necrotizing fasciitis. Material and methods. A clinical observation of a 57-year-old patient K. with complaints of pain in the area of the right foot, reddening of the skin on the right foot is presented. T — 37.2 ºC. To determine the nature of the revealed changes, the patient was referred to the Department of Radiation and Functional Diagnostic Methods for soft tissue ultrasound and computed tomography (CT) of the vessels of the lower extremities to assess the lesion and plan surgical treatment. Results. After an ultrasound of the soft tissues of the right leg posterior surface, around the gastrocnemius muscle, an inhomogeneous liquid rim (an echo picture of fasciitis), soft tissue edema was visualized. CT of the lower extremities vessels showed a decrease in blood flow in the lower leg arteries, infiltration and a moderate amount of gas in the soft tissues of n/3 of the lower leg and foot. Discussion. Necrotizing fasciitis (fasciitis necrotisans) is a representative of a large group of surgical infections of soft tissues, the morphological basis of which is progressive necrosis of the superficial fascia (fascia superficialis) and subcutaneous adipose tissue, and the clinical course is particularly severe and is accompanied by high mortality. NF is an emergency surgical situation. Early and accurate diagnosis is critical to provide the necessary aggressive treatment. Conclusion. This clinical observation demonstrates the importance of conducting a study using computed tomography and ultrasound in patients with necrotizing fasciitis for the earliest possible diagnosis and immediate surgical treatment, supported by effective antibiotic therapy.

Aortic-tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.

Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot.A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation.The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot. A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation. The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Appendix

Endovascular interventions in patients with glass iii infrainguinal arterial disease: 2-year results

To evaluate the results of endovascular surgery in patients with chronic limb-threatening ischemia (CLTI) with infrainguinal arterial disease GLASS III. Treatment outcomes were analyzed for the period 2017-2018. Inclusion criteria were age over 18 years, CLTI, extended (>20 cm) stenosis de novo and occlusion of femoropopliteal segment (FPS) combined with occlusive lesion of tibial arteries. We analyzed 147 patients divided into 2 groups depending on stenting strategy. FPS-1-TA included 53 patients who underwent angioplasty (± stenting) of femoropopliteal arteries and lower leg arteries resulted at least one patent tibial artery. FPS-2-TA enrolled 94 patients who underwent angioplasty of femoropopliteal arteries and lower leg arteries resulted ≥2 patent tibial arteries. Mean age was 71.0±9.8 years. There were 75 men. Demographics and clinical characteristics of patients were similar. Technical success rate was 100%. Mean length of stenting was 203 ± 99 mm. Occlusion of all 3 leg arteries correlated with high incidence of femoropopliteal stenting. In the FPS-1-TA group, stents were implanted in 39 patients, in the FPS-2-TA group - in 71 patients (73.6% and 75.5%, respectively, p=0.8). Braided nitinol stents were used for stenting of the lower third of superficial femoral artery and p1-p3 segments. Mean follow-up period was 22.6±1.1 months. Two-year results were not age-specific in our study. Kaplan-Meier overall survival, freedom from amputation and amputation-free survival for the entire sample were 79.6%, 81.0%, and 66.7%, respectively. We compared these values in both groups using Mantel-Cox log-rank test and obtained significant differences (67.9% vs 86.2%, p=0.004; 64.2% vs 90%, p<0.0001; 47.2% vs 77.7%, p<0.0001, respectively). Our results are comparable with literature data regarding freedom from amputation and amputation-free survival. We obtained significant differences in overall survival and freedom from amputation depending on endovascular strategy for tibial arteries. Correction of distal vessels with recanalization of at least two tibial arteries is advisable for endovascular treatment of diffuse complex lesions.

Long-term results of proximal and distal reconstructions in patients with lower limb arteries diffuse lesions and diabetes mellitus

Relevance . Treatment of diffuse lesions of the arteries of the lower extremities is often reduced to primary amputation at the hip level, since the healing of trophic ulcers is not guaranteed during arterial reconstruction. Profundoplasty without distal bypass surgery can be considered an alternative method. The aim of this study is to compare the long-term results of distal shunting and isolated profundoplasty in patients with diffuse lesions of the lower limb arteries and trophic ischemic ulcers. Materials and Methods . The study included 86 patients with diffuse lesions of the lower limb arteries. There were 52 (60.4%) men and 34 (39.6%) women. The average age was 67.3 16.8 years. All patients had diffuse lesions of the arteries below the pupar ligament, the state of the lower leg arteries was 5-8.5 points on the Rutherford scale, in all cases there were trophic ulcers. Group 1 included 48 patients who underwent reconstruction of the leg arteries. Group 2 consisted of 38 individuals who had limited intervention with endarcteriotomy from common femoral and deep femoral arteries. Results and Discussion . Amputations at the hip level were performed within a year in 11 (23.4%) patients of group 1 and in 3 (6.3%) patients within 30 days after surgery. Thus, 14 (29.7%) patients lost their limbs. A comparative analysis revealed that the group of patients with amputations had a more severe form of diabetes (p = 0.003), an outflow score on the Rutherford scale (p 0.001), and lower transcutaneous oxygen tension values before and after surgery. Within 12 months after the bypass surgery, the primary patency of the shunts was 65.9% (thrombosis occurred in 16 patients). Conclusion . The preservation of the limb in patients in our study by the end of 1 year after reconstruction is similar regardless of the reconstruction method. Given the minimal invasion during profundoplasty, this operation may be the method of choice for diffuse lesions of the arteries of the lower extremities.

Analysis of the vascular abnormalities of the patients with ankle joint mild osteoarthritis

The vascular factor is one of the leading pathogenesis factors in the formation of ankle joint osteoarthritis. Dystrophic and sclerotic changes in the joint tissues develop as a result of blood flow decrease. These mechanisms understanding will allow to plan treatment and rehabilitation measures, as well as predict and prevent complications. The purpose of the work is to study hemodynamic parameters in the main lower leg arteries of the in patients in follow-up period of mild ankle joint osteoarthritis. Two groups of patients were examined. The first group - 82 patients with mild ankle joint osteoarthritis in the follow-up period (10 years) and the second group - control (healthy) group of 58 people without ankle joint osteoarthritis. Duplex scan of the main lower leg arteries was performed to all the patients. The state of arteries and hemodynamic parameters were evaluated. Excell and STATISTICA 10.0 programs were used for statistical data processing. In patients with follow-up of mild ankle joint osteoarthritis, the diameter of the arteries did not differ from the control group. In patients with mild ankle joint osteoarthritis the thickness of the Intima-media complex in the lower leg arteries and walls pulsation were significantly higher than those in patients of the control group (p &lt;0.05). Analysis of hemodynamic parameters in patients with ankle joint osteoarthritis revealed an increase in the linear velocity of blood flow with a further tendency to normalization and even decrease in the follow-up compared with the control group. Signs of perfusion difficulty that accompanied the development of high blood pressure syndrome in the lower leg arteries were observed in 122 (67.0%) patients, and the signs of perfusion difficulty were bilateral in most of the cases (86.9%). Stenosis, deformation and arteries tortuosity were noted in 22% of patients with ankle joint osteoarthritis. Thus, mild ankle joint osteoarthritis is accompanied by blood flow changes in the form of inadequate perfusion and high-pressure syndrome in the lower leg arteries, which can cause secondary injuries and requires higher attention when selecting treatment and rehabilitation actions.

Methods for improving the results of using a synthetic prosthesis in the popliteal-tibial segment in critical limb ischemia

Aim. Analysis of immediate and long-term results of using a synthetic prosthesis for femoral-distal-popliteal and tibial bypass grafting in patients with critical lower limb ischemia.&#x0D; Materials and Methods. Patients with symptoms of chronic arterial ischemia of the lower extremities in the stage of critical ischemia (n = 109) were operated at the university surgical clinic on the base of D.D. Pletnev City Clinical Hospital, Moscow, in the period from 2009 to 2017. All the patients underwent the operation of femoral-distal popliteal or femoral-tibial bypass grafting using a synthetic explant (PTFE). Shunting with a synthetic prosthesis was performed in 33 (30.3%) patients, and in 76 (69.7%) cases a combination of an explant with a section of autovein was used in the form of a combined shunt in 44 patients (40.4%) (synthetic prosthesis + autovein) or a patch- or cuff plasty of distal anastomosis in 32 patients (29.3 %). In 14 (12.8%) patients of both groups, the intervention was supplemented by intraoperative balloon angioplasty of the lower leg arteries. Long-term results were evaluated within the period up to 5 years after surgery. Kaplan-Meyer survival analysis was used for the calculation of results.&#x0D; Results. The cumulative 5-year patency of the synthetic prosthesis was 42.9%. However, use of the prosthesis in combination with the autovein section in the form of a combined shunt or plastic surgery of the distal anastomosis significantly improved the values of cumulative patency (54.5%) and limb retention (83.6%).&#x0D; Conclusions. The results obtained make it possible to recommend the use of a synthetic prosthesis in combination with an autovenous plastic surgery of a distal anastomosis or by combining a prosthesis with a small section of an autovein in the absence of a complete autovein. Regular monitoring of such shunts in the long-term period and timely follow-up interventions are necessary for improving long-term results.

Mitochondrial Targeted Antioxidant Intake Improves Vascular Function And Exercise Tolerance In Peripheral Artery Disease Patients

Peripheral artery disease (PAD) is a manifestation of atherosclerosis in the lower leg arteries, which causes reduced blood flow and leg pain. This may be in part due to excessive mitochondria-produced reactive oxygen species (ROS) and attenuated mitochondrial respiratory function. Mitoquinol mesylate, a mitochondrial-targeted antioxidant, has been shown to scavenge ROS and improve vascular function in older adults and animal models. However, the impacts of mitoquinol on vascular function in patients with PAD are unknown. PURPOSE: To examine the impacts of acute mitoquinol intake (80mg) on endothelial function (flow mediated dilation, FMD), resting heart rate (RHR), blood pressure (BP), arterial stiffness (pulse wave velocity, PWV), and exercise tolerance in patients with PAD. METHODS: 10 patients with PAD (stage II-III) received either mitoquinol or placebo in a randomized crossover design. At each visit, measurements of RHR, central and peripheral BP, brachial and popliteal artery FMD, PWV, augmentation index (AIx), maximal walking capacity, and time to claudication (COT) were measured before and after mitoquinol and placebo. RESULTS: There were significant group by time interactions (p<0.05) for brachial FMD, popliteal FMD, and COT, which significantly increased (p<0.05). There were trends for decreases in diastolic BP (p=0.10), carotid-to-ankle PWV (p=0.08), and increases in maximal walking time (p=0.06), and maximal walking distance (p=0.06). There were no changes in RHR, systolic BP, central BP, deceleration time, max dP/dt, carotid-to-radial PWV, carotid-to-femoral PWV, or AIx (p>0.05). CONCLUSIONS: Mitoquinol intake may be an effective strategy for targeting mitochondrial ROS, which may be useful for treating endothelial dysfunction, leg pain, and improving walking time in patients with PAD.

Comparative results of isolated profundoplasty and distal bypass surgery in patients with diabetes mellitus and trophic ulcers

Aim. To compare the results of lower limb revascularization in patients with diffuse lesions of lower limb arteries who underwent femoral-distal bypass surgery and isolated reconstruction of the deep femoral artery (DFA) in the immediate postoperative period.Materials and methods. The study included 86 patients with diffuse arterial lesions of lower extremities, 52 (60.4%) men and 34 (39.6%) women with the average age of 67.3 ± 16.8 years. All patients had diffuse lesions of the arteries below the Poupart’s ligament; the condition of the lower leg arteries was 5–8.5 points on the Rutherford scale. Trophic ulcers were present in all cases. Group 1 included 48 patients who underwent reconstruction of lower leg arteries. Group 2 included 38 patients whose surgical intervention was limited to endarterectomy from the common femoral and deep femoral arteries.Results. In the early postoperative period, 1 (2.1%) patient (from group 1) died from developed myocardial infarction. The patient underwent a femoral-popliteal-tibial bypass surgery with a composite Y-shaped graft. In group 2, no fatal complications were observed. After the operation, all patients demonstrated an increase in the linear blood flow velocity in the arteries of the foot and the transcutaneous oxygen tension (TOT). The TOT level 14 days after surgery comprised 44.1 mm Hg and 39.9 mm Hg (p&gt; 0.05) in groups 1 and 2, respectively.Conclusions. In 86.8% of patients, isolated profundoplasty followed by vasotropic therapy allows the target values of TOT to be obtained, which is necessary for successful healing of lower limb trophic ulcers.

Quantitative Analysis of Lower Leg Muscle Enhancement Measured From Dynamic Computed Tomographic Angiography for Diagnosis of Peripheral Arterial Occlusive Disease

The purpose of this study was to evaluate whether quantitative analysis of lower leg muscle enhancement measured from dynamic computed tomographic angiography (dyn-CTA) could be used for diagnosis of peripheral arterial occlusive disease. Patients (N = 35) with known peripheral arterial occlusive disease underwent the dyn-CTA of calves first. Five minutes later, standard CTA of the peripheral runoff from the diaphragm to the toes was performed. A runoff score was assigned by radiologists as a reference standard for each of 4 lower leg artery segments. The lower leg muscle enhancement measured from the dyn-CTA was analyzed by using quantitative kinetic parameters, including initial enhancement (E1), peak enhancement (Epeak), and enhancement ratio (ER) calculated from average time attenuation curves. In addition, histogram of lower leg muscle enhancement was evaluated by using the first enhanced phase images. Lower extremities were diagnosed as a normal group (n = 22) with each vessel segment score equals to 1 or lower and runoff score, 7 or lower, and otherwise as an ischemia group (n = 48). Average ± SD E1 is 91.4% ± 8.5% and 82.3% ± 10.7%, Epeak is 122.7% ± 10.4% and 115.6% ± 11.1%, and ER is 0.75 ± 0.05 and 0.72 ± 0.09 for normal and ischemia group, respectively. Statistical analysis showed that average E1 and Epeak for the ischemia group were significantly lower (P < 0.05) than the normal group. The histogram analysis demonstrated that mean and median of muscle enhancement in the ischemia group were significantly smaller (P < 0.05), and coefficient of variation (CV) was significantly larger (P < 0.05) than the normal group. There were weak negative correlations (r = -0.42, P < 0.05) between runoff scores and E1 and Epeak, and weak positive correlation (r = 0.40, P < 0.05) between runoff scores and CV. The receiver operating characteristics analysis between the 2 groups had area under the curve of 0.77 and 0.76 for E1 and CV, respectively. Lower leg muscle enhancement measured from the dyn-CTA could be assessed quantitatively to assist diagnosis of ischemia in clinical practice.

Combined Endovascular Treatment of Acute Coronary Syndrome with Bioresorbable Scaffolds and Angioplasty in Patient with Critical Lower Limb Ischemia – Hybrid Treatment in Multidisciplinary Hospital

The key to successful treatment in patients with acute coronary syndrome is maximally early revascularization of the coronary arteries. Treatment of multifocal atherosclerosis with lesions of the coronary and peripheral arteries requires coordinated work of the multidisciplinary team of doctors. Critical ischemia of the lower limbs requires urgent revascularization in order to prevent limb amputation. However, it is not always possible to perform revascularization using specialists of the same profile – endovascular or surgical. The use of hybrid methods of treatment (surgical and endovascular) allows to significantly improve the prognosis in saving the limb. The article presents a clinical observation of successful multistep treatment of a patient with acute coronary syndrome in combination with critical ischemia of the lower limb. The first stage was performed by multiple stenting of the coronary arteries with bioabsorptive scaffolds; the second stage was the hybrid treatment – femoral-tibial bypass with simultaneous recanalization and angioplasty of the lower leg arteries with good postoperative and long-term outcome.

Automated Muscle Segmentation from Dynamic Computed Tomographic Angiography Images for Diagnosis of Peripheral Arterial Occlusive Disease

The purpose of this study was to quantitatively evaluating lower leg muscle ischemia measured from dynamic computed tomographic angiography (dyn-CTA) for patients with peripheral arterial occlusive disease (PAOD). A total of 35 patients with known PAOD underwent a dyn-CTA of the lower leg first with 70 kV tube voltage and 30 mL iodinated contrast media. Five minutes later, a standard CTA (s-CTA) of the peripheral runoff from the diaphragm to the toes was scanned. For each of four lower leg artery segments, a runoff score was given by a radiologist according to s-CTA images as a reference standard. The muscle enhancement measured from the dyn-CTA was analyzed by automated muscle segmentation using curve-based Fuzzy C-means (CBFCM) algorithms with three classes for bone, two classes for muscle and one class for fat and background. The muscle enhancement ratio (MER) was calculated for (i) higher enhanced area over total area; and (ii) corresponding average signal value at higher enhanced are over total area. Lower extremities were diagnosed as a normal group (n = 22) with each vessel segment score ≤ 1 and runoff score ≤ 7, and otherwise as an ischemia group (n = 48). The MER for the ischemia group was significantly different (p $\vert \text{r}\vert = 0.47$ , p < 0.05) between runoff scores and the MER values. The receiver operating characteristics (ROC) analysis between the two groups had area under the curve of 0.71-0.73. Our study demonstrated that CBFCM could be used for automated muscle segmentation from the dyn-CTA images for qualitatively evaluation of lower leg muscle ischemia.

Reference values of vessel diameters, stenosis prevalence, and arterial variations of the lower limb arteries in a male population sample using contrast-enhanced MR angiography.

IntroductionMorphological characterization of leg arteries is of significant importance to detect vascular remodeling triggered by atherosclerotic changes. We determined reference values of vessel diameters and assessed prevalence of stenosis and arterial variations of the lower limb arteries in a healthy male population sample.MethodsGadolinium-enhanced magnetic resonance angiography at 1.5 Tesla was performed in 756 male participants (median age = 52 years, range = 21–82 years) of the population-based Study of Health in Pomerania. Vessel diameters were measured in 9 predefined segments of the pelvic and leg arteries and 95th percentiles were used for upper reference values of means of left and right side arteries.ResultsReference values of vascular diameters decreased from proximal to distal arteries: common iliac = 1.18cm; internal iliac = 0.75cm; external iliac = 1.03cm; proximal femoral = 1.02cm; distal femoral = 0.77cm; popliteal = 0.69cm; anterior tibial = 0.42cm; posterior tibial = 0.38cm; fibular = 0.40cm. Body-surface area indexed reference values increased with age in all segments. A number of 53 subjects (7.0%) had at least one stenosis, mainly in the lower leg arteries anterior tibial (n = 28, 3.7%), posterior tibial (n = 18, 2.4%) and fibular (n = 20, 2.6%). The risk of stenosis increased considerably with age (odds ratio = 1.08; p<0.001). The most common arterial variant was type I-A in both legs (n = 620, 82%).ConclusionWe present reference values for different pelvic and leg artery segment diameters in men that decrease from proximal to distal and increase with age. Stenoses were most prevalent in lower leg arteries and type I-A was the most common variant in the lower leg.

Malignant soft tissue tumor, wide excision, and sural flap

Introduction: Soft tissue malignancy always appear in orthopaedic practice. The example of soft tissue malignancy is malignant melanoma. The treatment for soft tissue malignancy is wide excision. Soft tissue malignancy which done wide excision, can cause skin defect. Orthopedic surgeon need skin flap technique to coverage the skin defect after performed wide excision tumor. Case Report: This case report explains about wide excision of melanoma maligna in calcaneal region in patient male, 72-year-old and the defect in calcaneal region with sural flap. Melanoma maligna is a one type of skin cancer from melanocyte. Melanocyte is pigment-containing cells in the skin. The incidence of melanoma is increasing by every year (6% per year). The main treatment in melanoma is wide surgical excision of the tumor. Wide excision of the tumor in the calcaneal region can made defect of skin. Because of it, we can closure the defect which caused by wide excision with sural flap. Sural flap is fasciocutaneous flap, made up of skin, subcutaneous fat, superficial and deep fascia of the posterior part of the lower leg, sural nerve, sural vein, and superficial sural artery. Conclusion: We want to recommend sural flap as a good choice to closure defect it from wide excision of soft tissue malignancy (melanoma maligna) in the calcaneal region.