Multifocal Atherosclerosis Research Articles

Течение инфаркта миокарда у женщин трудоспособного возраста

The incidence of myocardial infarction (MI) among women of working age has continued to grow in recent years, being a great socio-economic problem. The purpose — to study the features of MI course in women under the age of 60. Results. The following risk factors were identified: hyperlipidemia (74.2%), arterial hypertension (AH) (69.4%), smoking (35.5%), obesity (37.1%), and diabetes mellitus (DM) (29.0%). Hyperuricemia (HU) occurred in 38.7% of patients. Repeated MI was observed in 3.2% of patients. Anterior and lower MI occurred with approximately the same frequency (45.2% and 40.3%, respectively). The percentage of coronary artery (CA) lumen stenosis was 81.2 ± 19.6%. Thrombosis with complete CA occlusion was detected in 61.3%. The percentage of brachiocephalic artery (BCA) lumen stenosis was 21.5 ± 7.5%. Thickness of the intima-media complex (TIMC) of BCA in the carotid artery bifurcation zone was 1.1 ± 0.2 mm on the right and 1.1 ± 0.2 mm on the left. We revealed a direct correlation between the level of uric acid (AU) and TIMC BCA (correlation coefficient 0.36; p ˂ 0.05) and an inverse correlation between the UA values and the glomerular filtration rate (GFR) (correlation coefficient 0.36; p ˂ 0.05), which indicates the important role of HU. Conclusions. Among the risk factors of MI development in women under 60 years of age, hyperlipidemia, hypertension, smoking, HU and DM are of the greatest importance. Hemodynamically significant stenosis was only in CA, multifocal atherosclerosis was not detected. HU is the most important factor of MI development in women. It has a negative effect on BCA and GFR and increases the likelihood of a brain stroke. It is necessary to include UA in the standards of examination of all forms of coronary heart disease. In case of a high cardiovascular risk, it should be reduced to the target level below 360 mmol/l to prevent cardiovascular complications.

Hybrid revascularization of chronic occlusion of the aorto-femoral segment in a patient with critical ischemia of the lower limbs and ischemic heart disease

Backgound. The number of patients with Leriche’s syndrome has increased dramatically. Despite the compensatory development of collaterals, this condition most often leads to symptoms of intermittent claudication and can result in critical ischemia and amputations. TASC II guidelines recommend reconstructive surgery, but this approach is associated with high perioperative mortality. So far, only few studies reported the results of endovascular correction of the atherogenic process in the infrarenal aorta.Objective. To present a clinical case of hybrid revascularization of the aortofemoral segment in a patient with ischemic heart disease.Design and methods. A 68-year-old patient with Leriche’s syndrome underwent ultrasound of the brachiocephalic arteries, coronary angiography, and multispiral computed tomography with angiography. Subsequently, hybrid surgery was performed.Results. Given the critical ischemia of the lower extremities and comorbidities, a hybrid surgical intervention was performed: endarterectomy from the femoral arteries and endovascular recanalization of the occlusion of the aortoiliac segment using the “kissing stents” technique.Conclusions. The requirements for equipment and experience of the surgical team limit the widespread use of hybrid correction of an occlusive lesion of the infrarenal aorta. The lack of randomized trials creates uncertainty in the choice of revascularization tactics. In the framework of this clinical case, the effectiveness of hybrid surgery in the treatment of a patient with multifocal atherosclerosis has been proven.

Long-Term Prognosis after Coronary Artery Bypass Grafting: The Impact of Arterial Stiffness and Multifocal Atherosclerosis.

The aim of the study was to study the effect of arterial stiffness and multifocal atherosclerosis on the 10-year prognosis of patients after coronary artery bypass grafting. Methods. Patients with coronary artery disease (n = 274) who underwent coronary artery bypass grafting (CABG), in whom cardio-ankle vascular index (CAVI) was assessed using the VaSera VS-1000 device and the presence of peripheral atherosclerosis in Doppler ultrasound. Groups were distinguished with normal CAVI (<9.0, n = 163) and pathological CAVI (≥9.0, n = 111). To assess the prognosis, coronary and non-coronary death, myocardial infarction, acute cerebrovascular accident/transient ischemic attack, repeated CABG, percutaneous coronary intervention, carotid endarterectomy, peripheral arterial surgery, pacemaker implantation were analyzed. Results. During the observation period, mortality was 27.7%. A fatal outcome from all causes was in 37 (22.7%) patients in the group with normal CAVI and in 39 (35.14%) in the group with pathological CAVI (p = 0.023). Death from cardiac causes was more common in the group with CAVI ≥ 9.0—in 25 cases (22.52%) than in the group with CAVI < 9.0—in 19 (11.6%, p = 0.016). The combined endpoint in patients with pathological CAVI was detected in 66 (59.46%) cases, with normal CAVI values—in 76 (46.63%) cases (p = 0.03). The presence of diabetes mellitus, multifocal atherosclerosis (p = 0.004), pathological CAVI (p = 0.063), and male gender were independent predictors of death at 10-year follow-up after CABG. The presence of multifocal atherosclerosis and pathological CAVI during the preoperative examination of patients were independent predictors of the combined endpoint development. Findings. Patients with coronary artery disease with pathological CAVI before CABG were more likely to experience adverse events and death in the long-term follow-up than patients with normal CAVI. Further studies are needed to investigate the possibility of correcting pathological CAVI after CABG after secondary prevention and the possible impact of this correction on prognosis.

Factors of unfavorable prognosis for myocardial and coronary revascularization using hybrid and step-by-step percutaneous interventions and carotid endarterectomy

Aim. The study aimed at analysis of unfavorable prognostic factors and creation of a prognostic model for choosing the optimal strategy for cerebral and myocardial revascularization using carotid endarterectomy (CEE) and percutaneous coronary intervention (PCI).Material and Methods. A total of 263 myocardial and cerebral revascularizations were performed using PCI and CEE in patients with multifocal atherosclerosis and concomitant carotid and coronary artery disease from 2011 to 2017. Depending on selected treatment strategy, the patients were divided into two groups: group 1 (n = 133) comprised patients with stepby- step interventions in different sequences (CEE and PCI); group 2 (n = 130) comprised patients who underwent hybrid interventions (CEE + PCI). A binary logistic regression was performed with step-by-step inclusion and exclusion of predictors in order to identify predictive factors in the long-term period. A multivariate analysis was also performed, and the odds ratios were determined.Results. The analysis allowed to identify the significant effects of certain factors on death, favorable outcome (the absence of significant adverse cardiovascular events), and the availability of revascularization. The following protective factors increased the probability of favorable outcome in the general sample of patients throughout the entire follow-up period: the absence of chronic obstructive pulmonary disease (COPD), EUROSCORE II score of less than 1.5, compliance with prescribed therapy, no need for repeated planned revascularization in the long-term period, no emergency hospitalizations in the long-term followup period, PCI via the radial access, and CEE using the classical method. The statistically significant factors in the created model included surgical risk score by EUROSCORE II scale (for the total sample of patients and for the staged and hybrid strategies) and the coronary lesion severity by SYNTAX Score (for the total sample of patients and the hybrid strategy). It should be noted that the hybrid strategy was associated with a significantly greater availability of revascularization during the follow-up period compared with the step-by-step strategy.Conclusion. An important outcome of this study was a comprehensive analysis of a wide array of factors (clinical-instrumental, anatomic-angiographic, and perioperative), which allowed to identify predictors of adverse (favorable) outcome in the long-term follow-up period in patients with combined coronary and cerebral lesions when using PCI and CEE as the revascularization strategies.

New Assessment of Overall Tolerance in the Rehabilitation of Patients in the Early Recovery Period of Ischemic Stroke

Enhanced external counterpulsation (EECP) has taken a worthy place among other methods in the complex treatment and rehabilitation of patients with cardiovascular pathology. Its use in outpatient and sanatorium-clinical practice significantly expands the prospect of treatment and improvement of prognosis in a wide range of patients with multifocal atherosclerosis. Aim. To study the effect of the EECP method in the complex medical rehabilitation of stable forms of coronary heart disease (CHD) in patients permanently residing in the resort city of Sochi. Material and methods. The study included 60 patients with CHD (FC II – 23, FC III – 29, FC IV – 8) living in the resort city of Sochi. Patients were randomized into intervention and control groups, in which there were no significant differences between clinical and anthropometric parameters. All of them received basic drug therapy, a complex of climatotherapeutic non-drug effects and attended the Coronary Club, a public health school for patients with СHD. Additional outpatient courses of EECP were conducted in the form of 35 one-hour sessions daily, 5 days a week, a full course for 7 weeks for each patient of the intervention group on basis. Initially and after the end of the rehabilitation course, the patients of both groups underwent electrocardiography (ECG), bifunctional daily ECG and blood pressure monitoring, Doppler echocardiography, ultrasound duplex scanning of brachycephalic vessels and lower limb vessels, exercise test on cycle ergometer, six-minute walking test, as well as physical activity level determination using IPAQ questionnaire and psychodiagnostic testing. Results and discussion. When comparing the data, patients in the intervention group showed a significant reduction in angina attacks and nitroglycerine use, stabilization of central haemodynamic parameters, increased exercise tolerance and improved subjective “quality of life” indicators. Conclusion. The data obtained confirm the experience accumulated in the world medical practice of the effective clinical impact of the EECP method in the treatment of patients with chronic coronary syndromes in outpatient treatment, including in conditions of humid subtropical climate. Therefore, its inclusion in the programs of complex sanatorium-resort rehabilitation of patients with stable forms of CHD is justified and promising.

Biomarkers of Apoptosis and Cell Proliferation in Diagnosing the Progression of Atherosclerosis in Different Vascular Pools

INTRODUCTION: The development and progression of atherosclerosis in different vascular pools remain unclear. Many studies have considered apoptosis to play a key role in the development of atherosclerosis; apoptosis is a programmed cell death with characteristic morphological signs aimed at providing homeostasis in an organism in general and in the vascular wall in particular. However, all studies that have been devoted to markers of apoptosis were mostly experimental and were conducted on either animals or grown cultures of different cells. The study aimed to examine markers of apoptosis (р53, sFas, Вах, and Всl-2) and proliferation (platelet-derived growth factor [PDGF] BB) in the vessel wall in the area of an atherosclerotic lesion in a patient with multifocal atherosclerosis. The clinical case was of interest because it allowed the assessment of biomarkers in both the area of progression of atherosclerotic lesion on an operated limb and the carotid pool in the long-term postoperative period.&#x0D; CONCLUSIONS: This case demonstrated that a patient with obliterating atherosclerosis of the lower limb arteries had an elevated level of pro-apoptotic markers р53 and Вах and PDGF ВВ as a marker of cell proliferation and migration, against the background reduced level of anti-apoptotic markers Всl-2 and sFas in comparison with their values in the normal arterial wall. The progression of atherosclerotic lesion in two vascular pools was associated with a further increase in the values of proapoptotic markers (р53 and Вах) and decrease in the values of Всl-2 and sFas compared with the initial samples. With this, the values of PDGF ВВ marker remained elevated relative to the initial level.

Glomus-Saving Autografting of the Internal Carotid Artery in the Peracute Period of Ischemic Stroke with Underlying COVID-19

INTRODUCTION: The severe acute respiratory syndrome coronavirus 2 is associated with the development of arterial thromboses of different locations. This pathology is common in patients with multifocal atherosclerosis. The overwhelming majority of published reports are devoted to the surgical treatment of patients with thrombosis of lower limb arteries. Thus far, no studies of revascularization in the case of extended atherosclerotic lesion and thrombosis of the internal carotid artery (ICA) in patients with COVID-19, have been published.&#x0D; AIM: To analyze the immediate results of glomus-saving autografting of the ICA with its extended atherosclerotic lesion and thrombosis in the peracute period of ischemic stroke in patients with COVID-19.&#x0D; MATERIALS AND METHODS: The retrospective study (inclusion period 01.01.201701.03.2020) involved 49 patients with hemodynamically significant extended atherosclerotic lesion of the ICA in the peracute period of acute cerebrovascular accident (ACVA). From April 1, 2020, to May 15, 2021, 26 patients with hemodynamically significant extended atherosclerotic lesion and floating thrombus in the ICA and a positive result of polymerase chain reaction to SARS-CoV-2 were included. In all cases, brain revascularization was performed in the peracute period of ACVA in the volume of glomus-saving autografting of the ICA.&#x0D; RESULTS: No adverse cardiovascular events were noted throughout the postoperative follow-up period in both groups. In the examination of the reconstruction zone using color duplex ultrasonography, no data for restenosis/thrombosis were recorded. On day 7 after surgery, in both cohorts of patients, significant regression of neurological deficit on the National Institute of Health Stroke Scale was noted: in the first group, the values during admission and day 7 after revascularization were10.5 3.5 and 6.5 1.5, respectively (р = 0.001); in the second group, the values were 12.5 2.5 and 5.5 1.5, respectively (р = 0.001). In both groups, no cases of unstable difficult-to-control arterial hypertension were noted, and no changes were introduced to the antihypertensive therapy.&#x0D; CONCLUSIONS: Emergency autografting of the ICA with its extended atherosclerotic lesion and thrombosis in the peracute period of ACVA is an effective and safe method of brain revascularization in patients with COVID-19.

PREDICTORS OF THE MAJOR CARDIOVASCULAR EVENTS IN THE EARLY AND MIDDLE-LONG TERM AFTER PERCUTANEOUS CORONARY INTERVENTION

Objective: To estimate predictors for major adverse cardiovascular events (MACE) in the early and middle-late periods after percutaneous coronary interventions (PCI). Design and method: The study included 116 patients (85% men and 15% women) with coronary artery disease (CAD) after PCI. In the early and middle-long-term periods MACE was developed in 24% of patients. The analysis of MACE predictors included wide range of clinical,angiographic,instrumental parameters,factors associated with the functions of the endovascular procedure,genetic testing. Results: There was not found predictive value of known risk factors, such as the presence of diabetes mellitus (DM) type II (OR = 1.75; 95% CI:0.54–4.62), smoking (OR = 1.51; 95% CI:0.64–3.56), hypertension (OR = 1.48; 95% CI:0.56–3.86), obesity (OR = 2.37; 95% CI:0.98–5.71), burdened heredity for CAD (OR = 2.16; 95% CI:0.85–5.48), a combination of several risk factors (DM+smoking) (OR = 2.17; 95% CI:0.65–7.28),DM+AH+obesity (OR = 2.97; 95% CI:0.83–10.61), chronic heart failure (OR = 1.7; 95% CI:0,53–5.46) on the risk of developing of MACE after PCI. It was found that significant MACE predictors in the early term period after PCI were: increased platelet reactivity in the presence of dual antiplatelet therapy (OR = 11.0; 95% CI:1.09–110.5) and carriage of polymorphic alleles of the fibrinogen-beta gene: alleles T (rs1800787) (OR = 4.7; 95% CI:1.07–20.2), alleles A (rs2227401) (OR = 4.9; 95% CI:1.12–21.1), alleles C (rs20426442) (OR = 4.9; 95% CI:1.12–21.1), in the middle-long term period: increased residual platelet reactivity despite of DAPT (OR = 11.67; 95% CI:4.29–31.71), decreased Antithrombin-III activity before and/or after PCI (OR = 5,5; 95% CI:1.4–21.68), SYNTAX Score &gt; 22 (OR-4.53; 95% CI:1.26–16.23), non-drug-eluting stent implantation (OR = 3,24; 95% CI:1.12–9.41), DAPT score &gt; 2 (OR = 3.15; 95% CI:1.3–7.64), the presence of multifocal atherosclerosis (OR = 2.91; 95% CI:1.15–7.39), LVEF &lt; 35% (OR = 2.52; 95% CI:1.05–6.03). Conclusions: Predictors of MACE in the early term after PCI were:increased residual platelet and the presence of genetic fibrinogen abnormalities, after middle-long term-increased residual platelet, failure to achieve the target lipid profile, decreased activity Antithrombin-III before and/or after PCI, SYNTAX Score &gt; 22, implantation of non-drug-eluting stents, DAPT score &gt; 2, presence of multifocal atherosclerosis, LVEF &lt; 35%. The frequency of known clinical risk factors, such as smoking, hypertension, DM, physical inactivity, obesity, burdened heredity for CAD, in the group of MACE patients was slightly higher, but did not reach statistical significance.

The relationship between the level of Lр(а) and the prevalence of atherosclerosis among young patients

Hyperlipoproteinemia (a) is an independent and cause risk factor for atherosclerotic cardiovascular diseases (ASCVD). The correlation between lipoprotein (a) Lp(a) and inflammation in the vessel wall was actively studied during the past few years. C-reactive protein (CRP) plays an important role in ASCVD. To analyze the relationship between hyperlipoproteinemia (a), inflammatory markers, and the early development of stenosing atherosclerosis (AS) in several vascular pools. 76 patients, 55 men aged 18 to 55 years and 21women 18 to 60 years, with the results of instrumental examination of coronary, carotid and lower extremities vascular pools were enrolled. Three groups: with stenosing (50%) AS of only one (group 1, n=29); two or three (group 2, n=21) vascular pools. 26 patients without coronary heart disease and AS were included in the control group. All patients in groups 1 and 2 and 65% of those in the control group took statins. The concentrations of Lp(a), CRP, lipids and blood count were determined. The patients of the three groups did not differ in age. In the groups with AS (79% in group 1 and 85% in group 2), there were more men (relative to 54% in the control group). Diabetes mellitus was more common only in patients with multifocal AS. The absolute number of blood monocytes and leukocytes, the neutrophil-lymphocyte ratio, as well as Lp(a) level were higher in patients of groups 1 and 2 relative to the control. The maximum Lp(a) level (median [25%; 75%]) was observed in patients with lesions of two or more vascular pools vs the control group (49 [4; 96] mg/dL, vs 10 [4; 21] mg/dL, p=0.02). The CRP level was significant elevated in patients from group 2 7.2 [4.0; 9.7] mg/L, relative to group 1 2.5 [1.0; 4.7] mg/L, and the control group 2.9 [1.2; 4.9] mg/L, p0.05. The Lp(a) and CRP concentration, or the presence of diabetes mellitus in patients, regardless of other risk factors, were associated with severe stenosing AS in young and middle age. An elevated concentration of Lp(a) (30 mg/dL) determines the presence of both isolated and multifocal stenosing AS in the examined patients. A simultaneous increase in the concentration of both Lp(a) and CRP, as well as the presence of diabetes mellitus, are associated with the premature development of stenosing atherosclerotic lesions in several vascular regions at once. Measurement of these predictors in young and middle-aged patients makes it possible to use them as biochemical markers to assess the likelihood of multifocal lesions of the vascular pool.

Some aspects of cardio-cerebral relationship in surgical patients with multifocal atherosclerosis and heart failure

Relevance . The level of cerebral perfusion in patients with multifocal atherosclerosis depends not only on the restriction of blood flow through the carotid arteries, but also on the degree of myocardial changes. Goal of investigation. Determine the presence of a relationship between the indices of regional cerebral blood flow according to SPECT data and echocardiographic parameters of cardiac activity and analyze the mechanism of their relationship. Material and methods . We examined 22 patients (18 men and 4 women aged 64 ± 6.5 years) with signs of chronic heart failure and multifocal atherosclerosis with the involvement of carotid and coronary arteries, who underwent simultaneous surgery. All patients underwent echocardiographic examination of the heart and SPECT of the brain. Results . Moderate direct correlations were revealed between the indices of regional cerebral blood flow (CBF) and ejection fraction (p = 0.009307), SV/EDV (p = 0.012431); moderate inverse correlations between the indices of CBF and SV (p = 0.002913), EDV (p = 0.031737), ESV (p = 0.016483), ESV/EDV (p = 0.010645), ESV/SV (p = 0.007255). In the postoperative period, a moderate direct correlation was found between indicators of cognitive status (MMSE) and indicators of cerebral perfusion in the right occipital, parietal and frontal lobes (p = 0.021162, R = 0.511475). Conclusion . The echocardiographic parameters we studied in patients with chronic heart failure correlate with indicators of regional cerebral blood flow, and this relationship is more pronounced not in the ejection fraction, but is traced between the parameters of the end diastolic volume, end systolic volume and their ratio according to the principle of the golden ratio. The data obtained on the perfusion of the brain by the SPECT method are associated with indicators of cardiac activity and reflect the severity of chronic heart failure.

Scope of endovascular surgery in correction of stenotic lesions of the internal carotid artery in complex anatomic conditions

In most cases, patients with multifocal atherosclerotic lesions, including brachiocephalic arteries, are denied surgical treatment due to the high risks of intra- and postoperative complications. Despite the severe stenotic lesion of the carotid arteries, which can lead to such a major complication as ischemic stroke, in most cases surgeons refuse to perform the operation. Endovascular surgery is often the only option for these patients. After analyzing the world experience in the treatment of hemodynamically significant lesions of the arteries of the brachiocephalic basin and applying in practice various methods of endovascular interventions in patients with complex stenotic lesions of the internal carotid arteries, we were convinced that endovascular correction of such lesions is often the main method of treatment for patients with multifocal atherosclerosis, and can also be used as a primary method of treatment, as it demonstrates high effectiveness, low risk of complications and good long-term results.

Three Year Prognosis of Patients with Myocardial Infarction Depending on the Body Weight Index: Data of the Kemerovo Acute Coronary Syndrome Registry

Aim. To study the effect of body mass index (BMI) on the 3-year prognosis of patients after myocardial infarction (MI).Material and methods. The study is based on data from a 3-year observation of patients with MI from the Kemerovo registry of acute coronary syndrome (n=1366). The characteristics of patients with MI, distributed by the BMI, were determined, the outcomes were analyzed, the risk factors and predictors for the vascular events and mortality were identified.Results. Obesity was detected in 32.2% people with MI (I degree – 22.3%; II – 7.7%; III – 2.3%), lack of BMI at 0.5%, normal BMI at 20.5%, overweight at 46.9%. Patients with different BMI showed a comparable incidence of recurring MI. In patients with normal BMI, when compared with patients with obesity, unstable angina pectoris (UA), heart failure (HF) and strokes developed often. In patients with normal BMI compared with obese patients, fewer deaths from all causes were recorded within 3 years after MI. A similar pattern with respect to the group with normal BMI in terms of high overall mortality was obtained among patients with overweight who had a lower UA. Patients with obesity was favorable in relation to the development of HF, strokes and overall mortality than patients with overweight. Differences in the 3-year outcomes in the group of patients with MI and underweight were not found when compared with patients with normal and overweight, however, they had a higher of strokes compared with patients with obesity. At patients with I degree obesity within 3 years after MI UA, HF, strokes were less. Patients with III degree obesity, the maximum frequency of total mortality was recorded. The development of death from all causes during the observation period in patients with MI and obesity was associated with: male, smoking, multivessel arterial diseases, non-endovascular reperfusion, acute HF with MI, history of vascular events and angina pectoris; whereas with overweight: multifocal atherosclerosis and arterial hypertension; with a deficit of BMI: non-reperfusion; with normal BMI: heredity for cardiovascular diseases, dyslipidemia and atrial fibrillation.Conclusion. 3 years after MI patients with obesity of the I degree are less likely than patients with obesity of II-III deaths from all causes are recorded; these patients are less likely than patients with normal weight to develop strokes, HF, UA. Thus, patients with MI and the presence of I degree obesity are characterized by better survival during 3 years of observation.

Clinical case of endovascular repair of abdominal aortic aneurysm in patient with multifocal atherosclerosis

Background. Until now, the issue of surgical treatment staging in patients with aortic pathology coexisting with coronary artery disease and atherosclerosis of the peripheral arteries remains controversial because of features of each clinical situation and association with the risk of periprocedural life-threatening complications (ruptured aortic aneurysm, myocardial infarction, stroke).Objective. Present a clinical case of successful treatment of a patient with an abdominal aortic aneurysm, clinically significant lesions of the coronary and carotid arteries.Design and methods. Diagnosis was carried out using computed tomography of the aorta with intravenous contrast. Instrumental examination included electrocardiography, echocardiography (EchoCG), ultrasound dopplerography of the BCA. Coronary angiography with BCA angiography was also performed.Results. Clinical diagnosis is an ischemic heart disease, angina pectoris III FC, chronic heart failure II FC and atherosclerosis of the aorta. Aneurysm of the abdominal aorta (diameter 96 mm), stenosing atherosclerosis of the BCA, PVCA stenosis 80 % and occlusion of the LVCA were observed. Patient had hypertension stage III and risk of CVE 4. Firstly, the patient was underwent stenting of the right internal carotid artery, than coronary artery bypass grafting and on the last stage he was performed — endovascular aotric repair. There were no complications in the perioperative period.Conclusions. Endovascular repair of abdominal aotric aneurysm is an effective method of treating patients with comorbid conditions. However, it is possible the development of fatal cardiovascular complications in patients with combined atherosclerotic lesions of brachiocephalic and coronary arteries that is why they are required a multidisciplinary approach for choosing a safe treatment strategy.

Prediction of clinical course in patients with diffuse coronary artery disease after coronary bypass surgery

Aim. To determine the incidence, predictors and develop a model for long-term risk stratification of ischemic events in patients with coronary artery disease after coronary bypass surgery.Material and methods. This retrospective study of the clinical course in patients with diffuse coronary artery disease (CAD) after coronary endarterectomy and bypass grafting surgery. A total of 232 patients were included, while long-term outcomes were assessed in 202 patients. Among them, complete data on clinical status were obtained from survivors (n=191). The median follow-up was 60 (interquartile range, 42; 74) months, while the minimum follow-up — 12 months, the maximum was 96 months. The primary composite endpoint reflecting the unfavorable course of CAD included coronary ischemic events (recurrent angina, myocardial infarction, repeat revascularization), while secondary endpoint — allcause mortality. The factors influencing the development of primary and secondary endpoints were studied.Results. An unfavorable CAD course was diagnosed in 39 patients (20,4%), while 11 deaths were recorded (5,4%). Univariate analysis demonstrated a significant role of prior myocardial infarction in the increase in mortality rate (p=0,029). Among the factors influencing the CAD course, no significant differences were obtained for any of them. A multivariate analysis was performed to identify a high-risk group for an unfavorable course of diffuse CAD. Independent predictors were identified, the most significant contribution of which was made by multifocal atherosclerosis (odds ratio (OR)=1,99, 95% confidence interval (CI), 0,93-4,21, p=0,072), low adherence to secondary prevention measures (OR=2,21, 95% CI, 0,86-6,89, p=0,128) and diabetes (OR=1,73, 95% CI, 0,79-3,72, p=0,162). Using the results obtained, a prognostic model with high specificity (64%) and moderate sensitivity (53%) was created.Conclusion. The highest probability of an unfavorable long-term course of diffuse CAD was noted in patients with diabetes, multifocal atherosclerosis, and low adherence to secondary prevention measures. The obtained results make it possible to identify a high-risk group in this cohort of patients, determine the reserve of secondary prevention measures and a direction of actions to improve outcomes.

Long-term outcomes of coronary artery bypass graft surgery in patients with widespread atherosclerotic lesions of the coronary and peripheral vascular basins (based on the REGATA long-term antithrombotic therapy registry)

Introduction . Multifocal atherosclerosis (MFA) in patients with CHD is a key risk factor for thrombotic complications (TC). There are little data on the long-term prognosis in patients with multivessel CHD combined with carotid artery lesions. Objective . To assess prognostic negative outcomes (thrombosis and bleeding) in patients with CHD and MFA undergoing revascularization procedures – coronary artery bypass graft surgery and, in case of high risk of ischemic stroke, carotid endarterectomy. Materials and methods . A total of 189 patients with stable multivessel coronary artery disease who successfully underwent coronary bypass graft surgery and had concomitant atherosclerosis of the carotid arteries ≥50% were included in the study. The exclusion criterion was chronic use of oral anticoagulants. The choice of antithrombotic therapy after the surgical intervention was determined by the attending physicians. The efficacy endpoint was defined as the sum of TC including cardiovascular death, acute coronary syndrome, ischemic stroke, acute lower limb ischemia, and the need for emergency revascularization of the carotid or coronary basins. BARC bleeding types 2-5 were considered as a safety endpoint. Results . The median follow-up period was 37 months. [MR 25.0; 45.0]. The cumulative incidence of TC was 11.1%, BARC 2-5 bleeding was 4.8%. One or two antiplatelet agents were prescribed at discharge in 87.3% of cases, and in 12.7% – a combination of acetylsalicylic acid (ASA) and oral anticoagulant (OAC) for up to 6 months. The incidence of thrombotic complications was not significantly different in the mono- or dual antiplatelet therapy groups. The combination therapy group (OAC + ASA) was characterized by the highest number of comorbidities. When analyzing the TC for the first 6 months. (before anticoagulant withdrawal) there was no significant difference between the groups of antiplatelet therapy and the combination of ASA and OAC (Log-Rank, p = 0.4669). The proportion of patients who survived the entire follow-up period without developing TC was significantly higher in the group compared to the initial combination therapy group: 0.83 versus 0.50 (Log-Rank, p = 0.0101). Conclusion . Despite complete revascularization, the incidence of TC during the two years of follow-up was high. In the combination therapy group, anticoagulant withdrawal led to an increased incidence of TC.

Modern strategies of antithrombotic therapy in patients with multifocal atherosclerosis

The manuscript is devoted to the problem of selection of antithrombotic therapy in the management of patients with multifocal atherosclerosis. The leading role of cerebrovascular pathology in the structure of mortality and causes of disability is noted. The questions of etiology and pathogenesis of acute cerebrovascular accident are considered. The pathogenetic subtypes of ischemic stroke and the criteria for their diagnosis were analyzed. The important role of antithrombotic therapy in the prevention of noncardioembolic stroke is presented. Considering the evidence-based medicine data based on the analysis of randomized trials results, modern strategies of antithrombotic therapy were demonstrated. A comparative analysis of the clinical trials results was carried out. New ideas about the benefits of combination therapy with acetylsalicylic acid at a dose of 100 mg/day and with rivaroxaban 2.5 mg twice daily, established in the COMPASS study, are presented.

MORPHOLOGICAL JUSTIFICATION OF THE SIGNIFICANCE OF LUMBAR ARTERIES IN THE PREVENTION OF SPINAL CORD ISCHEMIA IN ATHEROSCLEROTIC LESIONS OF ABDOMINAL AORTA.

The aim: To investigate atherosclerosis of the abdominal part of the aorta and atherosclerosis of the lumbar arteries, aimed at improving surgical tactics during reconstructive interventions on the abdominal part of the aorta in patients with multifocal atherosclerosis. Materials and methods: 20 autopsies were performed. The macro preparation consisted of the part of the abdominal aorta 1х1 sm taken along with a separated lumbar artery for 1-1,5 sm. Histological cuts were coloured with hematoxylin and eosin. The histochemical research was conducted in order to establish changes in all layers of blood vessels. The immunohistochemical research was carried out along with generally accepted histological methods in 10 cases to determine the morphological vessel wall functional state, connective tissue and smooth muscle components. Results: In all cases there were morphological signs of aortic atherosclerosis with different degrees of damage to the lumen. In none of the analyzed cases did we establish pathomorphological signs of atherosclerosis of the lumbar artery distal to the mouth. In the walls of the lumbar arteries, we noted the preservation of the layered structure, the integrity of the endothelial cells, the normal arrangement of smooth muscle cells. Conclusions: It was established that there cannot be the atherosclerotic occlusion of the lumbar artery, since there are no signs of atheromatous lesions in its walls, the structure of all layers is preserved, the endothelial damage is absent, the location and structure of the lining cells is normal.

The influence of comorbidities in the development of respiratory and pleural complications in post-op period during surgical procedures on descending thoracic aorta

Aim: The frequency and structure of emerging pulmonary and pleural complications after interventions on the descending thoracic aorta were studied. Material and Methods: Based on the experience of interventions on the aorta in 84 patients, the influence of concomitant diseases on the incidence of pulmonary and pleural comzplications after interventions was studied. Results: Revealed with a high degree of certainty (p≤0.05) in the group of patients with complications, patients initially had kidney disease (p=0.02), previously operated aortic aneurysm of another localization (p=0.04), arterial hypertension (p=0, 05), IHD (p&lt;0.01), multifocal atherosclerosis (n=0.01), COPD (n=0.01), Aortic dissection IIIB type (p&lt;0.01). Conclusion: Taking into account the identified patterns in the development of complications, we consider it necessary to take a more thorough approach to the prevention of these complications in the perioperative period.

Peculiarities of influence of atherosclerotic lesion of lower limb arteries on long-term outcomes in patients with multifocal atherosclerosis

Peculiarities of influence of atherosclerotic lesion of lower limb arteries on long-term outcomes in patients with multifocal atherosclerosis

Carotid endarterectomy for atherosclerotic occlusion of the contralateral internal carotid artery

Aim. To analyse perioperative and long-term results of carotid endarterectomy for occlusion or stenosis of the contralateral internal carotid artery.Methods. This study included 184 patients who underwent carotid endarterectomy for either occlusion (group 1, n = 74) or stenosis (group 2, n = 110) of the contralateral internal carotid artery. Carotid endarterectomy with eversion was performed in 97% of the patients while the conventional procedure with a patch was used in the remaining 3%.Results. The incidence of perioperative stroke / transient ischemic attack (TIA) in groups 1 and 2 was 1.35% and 1.82%, respectively (p = 0.806). Stroke / TIA within 30 days after surgery occurred in 2 patients in group 1 and in 1 patient in group 2 (p = 0.346); however, none were associated with death. In contrast, 3 cases of myocardial infarction (MI) were seen in group 1, two of which resulted in death. No instances of MI were seen in group 2. Long-term freedom from stroke and myocardial infarction, estimated using the Kaplan-Meier method, was not significantly different between the groups (p = 0.240 and p = 0.657, respectively). Long-term survival was similar in both groups (p = 0.281). An analysis of the risk factors for major cardiovascular events, both immediate and in the long-term, showed that plaque instability was the most significant (p = 0.004), followed by lesions in the arteries of the lower extremities (p = 0.002).Conclusion. Short-term and long-term cerebral complications were not significantly different between patients with occlusion or stenosis of the contralateral internal carotid artery. However, patients with occlusion were significantly more likely to experience MI, necessitating a detailed diagnosis of coronary artery disease. Instability of the atherosclerotic substrate and multifocal atherosclerosis were identified as independent risk factors for major cardiovascular events. Received 18 May 2021. Revised 30 July 2021. Accepted 11 August 2021. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authors: Authors contributed equally to this article.