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Aim: To present own experience of subclavian-carotid replacement for chronic cerebrovascular insufficiency management., Material and Methods: For 12 years 7 subclavian-carotid reconstructions were performed that was 1.2% of all carotid repairs during this period. Great saphenous vein was always used as a graft. Carotid endarterectomy from proximal internal carotid artery was additionally performed if it was necessary. Patients had severe advanced lesion of supra-aortic vessels including bilateral carotid lesion and significant stenosis of ipsilateral proximal common carotid artery. The vast majority of them had cerebrovascular insufficiency grade 3-4., Results: All patients underwent surgery without significant complications despite initially severe state due to advanced lesion of brachiocephalic arteries. Long-term postoperative patency of the grafts was satisfactory within the period from 12 years to 1.5 months. There were no neurological impairment and stroke., Conclusion: Subclavian-carotid grafting is an effective alternative for carotid endarterectomy in patients with advanced atherosclerotic lesion of common and internal carotid arteries.

Questions of saving of the patient's blood and limitation of the use of donated blood in the aortic surgery remain relevant in contrast with interventions on the valves of the heart and coronary arteries. In this regard, the aim of the study was to develop and introduce ofcomplex of technologies for saving the patient's blood in order to minimize transfusion of donor blood components during operations on the ascending aorta and aortic arch under hypothermic arrest. The study included 37 patients operated on the ascending aorta and aortic arch under cardiopulmonary bypass (CPB) and hypothermic cardiac arrest (CA) in 2013-2014 (Group 1). 2nd group consisted of 65 patients who at the same time performed reconstructive surgery on the ascending aorta with CBP without stopping the blood circulation. The comparative aspect studied the following parameters: duration of the CBP, CA, temperature, volume of intraoperative and postoperative blood loss, frequency of use of donor blood components autoplasma, washed red blood cells, autologous blood, hemostatic agents, the frequency resternotomy, hematocrit dynamics, glucose, and blood lactate. Comparative studies have shown that the amount of intraoperative blood loss during operations on the aortic arch under the CA was 1294 ± 303 mL, 20% higher than the blood loss during operations on the ascending aorta without CA. Program of saving of the blood of patients with aortic disease included preoperative preparation of autoplasma in 60% of patients, intraoperative collection and laundering of autoerythrocytes in 40-70% of patients and autotransfusion modified method, the improvement of surgical and pharmacological hemostasis and monitoring. Design and implementation of these methods reduced the patients need for donor red blood cells (from 76 to 47%), fresh frozen plasma (from 65 to 35%) during the operation at the aortic arch and the ascending aorta and to completely avoid the use of donor blood in 25% of patients. Proof of the adequacy of the developed strategy of conservation and limitation of the patient's blood was allogeneic blood conservation targets hemoglobin, hematocrit levels and metabolism at the end of the operation.

The simultaneous surgical treatment of ischemic heart disease (coronary bypass grafting) and ascending colon cancer (right hemicolectomy) is described. Literature review showed that these simultaneous surgical heart and colon procedures are reasonable and should become a method of choice for such patients.

Over 5-years, 167 reconstructive surgeries for stenosis of internal carotid arteries (ICA) were performed in 124 patients. Mean age of the patients was 63.5 years. One hundred and twenty-nine carotid endarterectomies (CEAE) in 86 patients and 38 reconstructive operations of ICA in 38 patients were performed. There were no lethal outcomes in short- and long-term postoperative period. In short-term period after prosthesis of ICA restenosis was revealed in 3% patients, after eversion CEAE in 3% patients the embolism was seen, after standard CEAE restenosis were diagnosed in 8% patients and thrombosis -- in 3%. In long-term period after grafting of ICA the strokes were seen in 3%, stenosis -- in 6% patients, after eversion endarterectomy -- in 0 and 3% patients, and after standard CEAE -- in 3 and 24% patients, respectively. It is concluded that grafting of ICA is adequate surgical method of reconstruction and stroke prevention in specific variants of carotid atherosclerosis.

The paper analyzes anesthesiological maintenance of infusion therapy, optimal criteria for effective brain protection, complications and mortality in 42 patients during operations on the ascending portion and arch of the aorta under deep hypothermic circulatory arrest. For this purpose, the patients were divided into 2 groups: Group 1 comprised 20 patients operated on before 1998; Group 2 included 22 patients operated on in 1998 to 2001. In both groups, circulatory arrest lasted 44 +/- 7 min. The patients were cooled to a temperature of 13.5 +/- 0.5 degrees C, to 15 +/- 0.6 degrees C in the nasopharynx. The duration of cooling was 58 +/- 5 and 73 +/- 6 min, respectively; that of warming-up was 70 +/- 8 and 83 +/- 6 min. Investigations have indicated that determination of the optimum brain cooling requires a complex assessment of central temperature values, electroencephalographic monitoring (visual estimation of a curve and quantitative characteristics), SjbO2 and cerebral metabolism. The investigations have shown that the procedure for anesthesiological maintenance and cerebral metabolism is safe and effective even in patients with arrested circulation lasting longer than 60 min. The operative mortality does not depend on the use of circulatory arrest under deep hypothermia and on its duration. Hemodynamic instability due to bleeding, as well as myocardial infarction, marked hemodilution during extracorporeal circulation are major factors that cause an increase in the rates of incidence of complications and mortality. The procedure used for anesthesiological maintenance and infusion therapy, decreased blood loss, and a reduction in the incidence of myocardial infarction could significantly reduce operative mortality. The fact that there were no neurological complications even during prolonged (80-min) circulatory arrest has shown that the brain-protective procedure including both general and regional cooling is reliable and to the extent of the indicated criteria. So is pharmacological protection.

45 patients aged 32-63 years operated on for dissecting aneurysm of the thoracoabdominal part of the aorta were divided into 2 groups. Group 1 patients (n = 36) were operated on with application of the bypass using centrifuge pump. Group 2 patients (n = 9) were operated on without the bypass. The results evidence that the employed anesthesia and infusion therapy in combination with the bypass maintained by the pump provide stable intraoperative hemodynamics and prevent renal failure. Usage of the bypass in combination with liquor drainage reliably protects spinal cord from ischemia, especially in patients with long-term aortic ligature.

Eighty-eight anesthesias in patients operated on the lower limb vessels are analyzed. In group 1 (77 pts) combined spinal-epidural anesthesia (CSEA) was used, in group 2 (16 pts) epidural anesthesia (EA). Segmentary blocking was induced by 2% lidocaine and 0.5% bupivacaine. CSEA was characterized by a shorter (in comparison with EA) latent period (12.9 +/- 1.3 min vs. 24.7 +/- 3.4 min, p < 0.05), a lower dose of bupivacaine (lidocaine: 735 +/- 89 mg in CSEA and 848 +/- 92 mg in EA; bupivacaine: 28.3 +/- 7.2 mg in CSEA and 92.6 +/- 8.5 mg in EA, p < 0.01), and a higher reliability. Combined anesthesia with bupivacaine is characterized by a greater contribution of the spinal component (than with lidocaine) and thus improve the quality of anesthesia, decrease the anesthetic dose, and maintain the stability of hemodynamic parameters. Four cases with inadequate blocking were due to erroneous position of the epidural catheter. Accidental perforation of the dura mater occurred in two patients, and prolonged spinal anesthesia was carried out. No headaches ensued. Hence, CSEA should be preferred to common prolonged EA in operations on the lower limb vessels.

The efficacy of combined spinal epidural anesthesia (CSEA) for femoral to distal artery bypass surgery is assessed. Thirty-eight patients were divided into 3 groups. CSE block was performed at L3-L4 (26G pensil-point spinal needle and 18G catheter). In group I (n = 14) blocking was induced with 20 mg of 1% lidocaine and maintained with 2% lidocaine through an epidural catheter. Group II (n = 15) received spinal plain 20 mg of 0.5% bupivacaine. In group III (n = 9) the initial dose of plain 0.5% bupivacaine was 3 ml (15 mg); 5 min after the first bolus the incremental dose of plain bupivacaine 3 ml (15 mg) was injected and spinal needle was withdrawn. Epidural 0.5% bupivacaine was injected as needed. Sensory blockade was assessed by the pinprick test. Two patients in group I (18.2%) were in need of general anesthesia (GA) (inadequate dissemination of solution in 1 case and catheter kinking in the other). In group II GA had to be performed in 1 case because surgery was longer than planned. In group III anesthesia was effective in all cases. The mean level of sensory block in group I was T11.2 +/- 0.4, in group II T9.4 +/- 0.5, and in group III T8.6 +/- 0.55 (p > 0.05). The mean dose of bupivacaine per segment in groups II and III was 1.47 +/- 0.08 and 2.08 +/- 0.01, respectively (p < 0.05), use of epidural catheter during surgery 40 and 11%, respectively (p < 0.05). Arterial pressure drop was 10.8, 14.1, and 11.6% in groups I, II, and III, respectively. The mean total dose was 735 +/- 89 mg (172 +/- 14 mg/h) in the lidocaine group, in group II 38.5 +/- 6.4 mg (10.25 +/- 1.15 mg/h), and in group III 32.8 +/- 2.8 mg (7.46 +/- 1.67 mg/h) (p < 0.05). No neurological problems or PDPH were observed in any of the patients and no vasoactive drugs were needed. CSEA is fit for anesthesia for peripheral vascular surgery. CSEA with double spinal injection is preferable, for it provides a longer anesthesia and hemodynamic stability.

Dilazin in a dose of 0.2 mg/kg/min (n = 20) and 0.4 mg/kg/min (n = 20) was used to normalize arterial blood pressure during and after surgery. Intravenous infusion of the drug decreased the arterial pressure to baseline values within 2-3 min by reducing the elevated systemic vascular resistance. Dilazin did not affect the heart rate, mean pulmonary capillary wedge pressure, or central venous pressure. The drug brought about a marked increase of cardiac output and cardiac index. Prompt effect and easy control, when dilazin is infused in a dose of 0.2 to 0.4 mg/kg/min, recommend it as an alternative antihypertensive agent to be used during various procedures.

Bioelectric activity and metabolism of the brain were studied during surgery on the aorta with deep hypothermal arrest of circulation. The study included 9 patients (7 men and 2 women) aged 13 to 66 years. The mean duration of circulation arrest under deep hypothermia was 48.6 (from 19 to 77) min. Before circulation arrest the patients were cooled to nasopharyngeal temperature of 13.5 +/- 0.5 degrees C and rectal temperature of 15 +/- 0.6 degrees C. Deep hypothermia involved the disappearance of bioelectrical activity and decrease of the spectral power of all EEG frequency bands. The most notable changes in the hemoglobin saturation of the blood in the internal jugular vein bulb (SibO2) were observed during artificial circulation and hypothermal arrest of circulation. Cooling of patients led to a gradual increase of its values. Before deep hypothermal arrest of circulation SjbO2 was as high as 98.4 +/- 0.4%. Over the period of circulation arrest its level dropped to 85.7 +/- 4.8%. Subsequent warming led to its further decrease, and by the end of artificial circulation it was as initially. The content of carbon dioxide in the blood flowing from the brain increased from 17.0 +/- 0.9 to 31.7 +/- 4.7 mm Hg over the period of heart arrest, which may be indicative of the continuing metabolic processes in the brain under conditions of deep hypothermia and justifies the additional drug protection and local hypothermia of the head.

Continuous spinal anesthesia with hyperbaric solution of 1% lidocaine and 0.375% bupivacaine and combined spinal-epidural anesthesia with solutions of 2% lidocaine and 0.375% bupivacaine by using in-run anesthesia ensure adequate anesthesia and persistent hemodynamic parameters during operations on lower extremity vessels. These procedures can be used in elderly high-risk patients.

Monitoring of brain metabolism is used to assess the adequacy of brain cooling during operations performed under conditions of deep hypothermal perfusion and temporary arrest of circulation. Such monitoring consists in continuous recording of hemoglobin saturation of the blood flowing from the brain by fiberoptic oximetry and testing of blood samples collected from the upper internal jugular bulb. A patient is described, who had been operated with good results under conditions of deep hypothermal perfusion and 30-min arrest of circulation.

Changes in hemodynamics and some metabolic parameters were studied in 78 patients during anesthesia for resection of the abdominal aorta aneurysms. The steps of the operation associated with the most profound hemodynamic changes were distinguished and measures aimed at stabilization of hemodynamics, blood volume, and electrolyte balance considered. No appreciable changes in the hemodynamics or depression of the myocardium were observed at stages of anesthesia and operation. A correlation was traced between pressure changes in the pulmonary artery and central venous pressure. The suggested method of anesthesia and infusion therapy strategy are conducive to stabilization of the hemodynamics in the course of the whole operation, to maintenance of normal volume of circulating blood and adequate diuresis. Monitoring of central venous pressure is sufficient to control infusion therapy and hemodynamics.

The effects of nitroglycerin on central hemodynamics and direct myocardial contractility were directly studied in 32 patients with functional class III-IV heart failure during aortocoronary bypass surgery. When nitroglycerin was used, hemodynamic parameters changed in two stages: 1) systemic blood pressure initially slightly increased; 2) decreases in this and other central hemodynamic parameters occurred. The dynamics of myocardial function was determined by its baseline state, dyskinetic intensity, i.e. its contractility. In patients with preserved myocardial function, nitroglycerin failed to cause its substantial dysfunction. At the same time its contractility and central hemodynamic parameters might considerably deteriorate in patients with moderate dyskinesia and furthermore with severe myocardial dysfunction.

Halothane impact on cerebral blood flow, brain metabolism and its protective effect in ischemia have been assessed in 30 patients operated on for the occlusion of brachiocephalic arteries. The data obtained indicate that additional use of halothane in N2O:O2 anesthesia during reconstructive surgery on brachiocephalic arteries makes it possible to enhance collateral blood flow, increase retrograde pressure, and decrease O2 consumption by the brain, without considerable changes in systemic hemodynamics. In addition, the studies have shown that halothane decreases lipid peroxidation processes.

A new analgesic fenaridine which was used as a component of balanced anesthesia in 160 operations of aortocoronary bypass has been studied. It has been shown that fenaridine is a potent analgesic, exceeding fentanyl in the duration of action and in its analgetic effect. Fenaridine has a pronounced sedative effect and like other analgesics causes a dose-dependent depression of respiration. The drug has a vasodilating activity, causing both venous and arterial dilatation. This leads to a decrease in CVP by 25-30%, on the one hand, and to a drop in BP by 20%, on the other hand. Fenaridine decreases Vmax and dP/dt by 18 and 20%, respectively, with a parallel decline in HR by 13% from the baseline. A marked vasodilating effect and potentiation of the action of diazepam and other benzodiazepines in prompt injection of both drugs or when the maximum dose of fenaridine is used may lead to the onset of hypotension, and thus the drug should be used with care in critical patients with hypovolemia. The use of lower fenaridine doses (not exceeding 0.001 mg/kg) and slow injection (up to 11-13 min), as well as its combination with ketamine at a dose of 1.5 mg/kg makes it possible to avoid these unfavourable adverse events and to ensure smooth induction even in critically ill patients.

Application of a shunt is not the principal factor preventing brain blood flow disorders in reconstructive surgery on the carotid arteries in conditions of general anesthesia with anesthetics of an antihypoxic action, reducing oxygen consumption by the brain, combined with adequate compensation of the circulating blood volume, moderate hemodilution, elevation of the systemic arterial pressure and heparin. The authors claim that even in patients with bilateral stenosis of the carotid arteries or with occlusion of one of these arteries surgery may be carried out without shunts or craniocerebral hypothermia. Still, they do not deny a bypass application, particularly by the surgeons who always use it, or in cases with a drastic inhibition of the brain electrical activity, evidenced by EEG, which they consider a sufficiently reliable indicator of the brain blood flow adequacy.

It has been demonstrated that transfusions of large amounts of stabilized donor blood and prolonged ischemia due to clamping of the abdominal aorta during surgery were not accompanied by an increase in K+ plasma level thanks to therapy aimed at the correction of hypovolemia and hemodynamic stabilization. A decrease in K+ plasma level directly depended on the volume of the liquid transfused, the degree of hemodilution and to some extent on 2,3-DPG level. There was a drop in 2,3-DPG level intraoperatively, which was due to the use of stored donor blood for blood loss compensation and to mounting metabolic acidosis (lactate acidosis included) and gaseous acidosis.

To evaluate the efficacy of combined cold and pharmacological protection of the myocardium in aortocoronary shunting, study of myocardial ultrastructure with quantitative stereological analysis of the mitochondria was conducted in 56 puncture biopsies; the material was collected in 28 patients with chronic ischemic heart disease before the aorta was clamped and after the clamp was removed. The period of anoxia did not exceed 68 minutes. The absence of irreparable morphological changes in the cardiomyocytes correlated with the character of restoration of cardiac activity and function after the operation, which allowed the conclusion that this is an effective method for protecting the myocardium of patients with chronic ischemic heart disease from anoxia during 68 minutes of cardioplegia.

The authors assess the diagnostic value of several enzyme and isozymic tests used in the diagnosis of myocardial infarction in aortocoronary shunting (ACS): the diagnostic sensitivity and specificity, as well as the significance of both positive and negative results, and the diagnostic efficacy of every test have been estimated. Ninety-one patients subjected to autovenous ACS have been examined for the total creatine kinase (CK), lactate dehydrogenase (LDH), aspartate and alanine aminotransferase activities, and for the activities of CK and LDH isozymes. The results evidence a high diagnostic value of CK and LDH isozymes measurements. A comprehensive study of these isozymes is a reliable criterion of the diagnosis of myocardial infarction. If myocardial infarction in ACS is diagnosed on the basis of the total enzymic activities, measurements of the transaminases and LDH are advisable; investigation of CK total activity is of poor informative value.

Cardiac hemodynamics and myocardial contractility were examined in patients with acute myocardial infarction during urgent aorto-coronary shunting with and without beta-adrenergic blockers. The beta-blockers were shown to have a protective effect, as reflected in a smaller myocardial strain owing to a decrease in heart rate, stroke and cardiac outputs, and pulmonary arterial blood pressure. Propranolol proved the most effective agent, whereas visken produced the smallest effect.