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and complications. Analysis methods in 640 patients with peripheral atherosclerosis showed that the incidence of complications are at low risk (< 0) in 2 % ofcases, with an average (0.5-2) - 12.8 %, with a high (2.5-4) - 23 %, and very high (< 4.5) - at 42.2 % cases (C - 0.76) [13].
Numerous methods listed above can only help assess the impact of risk factors on a disease course. Each tool has its own limitations. Studies revealed that all cardiovascular diseases and the majority of subjects initially entered at high risk group.
Conclusions
Thus, patients with combined lesions of arterial beds initially treated in a group with high risk for complications such as myocardial infarction, ischemic stroke and mortality. Application assessment SMART technique allows to predict possible complications in the postoperative period. Patients with a high grade of SMART score must pass before operating, adequate therapy directed to the elimination of risk factors.
References:
1. Dadov L. V., Nosenko N. S. et al. Features of atherosclerotic lesions of brachiocephalic arteries in patients with diabetes mellitus type 2// Cardiology. - 2007. - № 10. - P. 45-50. (Russian).
2. Bart V., Willem E., Frans L. Carotid atherosclerotic plaques in patients with transient ischemic attacks and stroke have unstable characteristics compared with plaques in asymptomatic and amaurosis fugax patients//J Vasc surg. - 2007. - 34: 1075-1081.
3. Beckman J., Preis O., Ridker P., Gerhard-Herman M. Comparison of usefulness of inflammatory markers in patients with versus without peripheral arterial disease in predicting adverse cardiovascular outcomes (myocardial infarction, stroke, and death)//Am J Cardiol. -2005. - 96: 1374-1378.
4. Ralf W. S., Kristel J. M., Frans L. M., Marianne C. V. SMART - Second Manifestations ofARTerial disease//J Vasc Surg. - 2009. -50: 1369-1377.
5. Cacoub P., Abola M., Baumgartner I., Bhatt D., Creager M., Liau C. et al. Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the Reduction of Atherothrombosis for Continued Health (REACH) Registry//Atherosclerosis. - 2009. -204: 86-92.
6. Edward O., Hebert B. et all. Clinical factors associated with long term mortality following vascular surgery: Outcomes from The Coronary Artery Revascularization Prophylaxis (CARP) trial//J Vascular Surgery. - 2007. - V. 46: i4. - P. 695-700.
7. Haugen S., Casserly I., Regensteiner J., Hiatt W. Risk Assessment in the patient with established peripheral arterial disease//Vasc Med. - 2007. - 12: 343-350.
8. Sabatine M., Morrow D., Jablonski K., Rice M., Warnica J., Domanski M. et al. Prognostic significance of the centers for disease control/american heart association high-sensitivity C-reactive protein cut points for cardiovascular and other outcomes in patients with stable coronary artery disease//Circulation. - 2007. - 115: 1528-1536.
9. Verhave J., Hillege H., BurgerhofJ., Gansevoort R., de Jong P. The association between atherosclerotic risk factors and renal function in the general population//Kidney Int. - 2005. - 67: 1967-1973.
10. Laura G. Etiologic factors in progression of carotid stenosis: A 10-year study in 905 patients//J Vasc Surg. - 2000. - 31: 31-38.
11. Welten G., Schouten O. et al. The influence of aging on the Prognostic Value of the Revised Cardiac Risk Index for Postoperative cardiac Complication in Vascular Surgery Patients//Eur J Vasc Endovasc Surg. - 2007. - 34: 632-638.
12. Welker J., Isherwood J., Eveson D., Naylor A. Triaging TIA/Minor Stroke Patients using the ABCD2 Score Does Not Predict those with Significant Carotid Disease//Eur J Vasc Endovasc Surg. - 2012. - 43: 495-498.
13. Pros N., Cambou J., Aboyans V., Malloizel D., Constans J. A hospital discharge risk score for 1-year all-cause mortality or non-fatal cardiovascular events in patients with lower-extremity peripheral artery disease, with and without revascularisation//Eur J Vasc Endovasc Surg. - 2013. - 45(5): 488-496.
Sobirov Jasur Gaybillaevich, MD, Senior Researcher, Department of vascular surgery, JSC «Republican Specialized Surgery Center named after academician V. Vakhidov» E-mail: s.jasur@mail.ru Bahritdinov Fazlitdin Shamsitdinovich, MD, PhD, Head of the Vascular Surgery Department E-mail: fbahritdinov@gmail.com
Types of aortic arch branches lesions in the patients with concomitant atheroscleroses
Abstract:
Objectives: to study types of lesions of the aortic arch branches of the patients with concomitant lesions of the aortic arch
branches, terminal part of the abdominal aorta and lower limb arteries.
Material and methods. analyzed the results of examination of181 operated patients with concomitant lesions of aortic arch
branches and lower limb arteries. All patients were divided into three groups: Group one — patients who underwent the first
stage of the reconstruction carried out in the aortic arch branches (number of patients — 31 (17.1 %)); Group two — patients
who underwent the first stage of reconstruction of a terminal portion of the abdominal aorta and lower limb arteries (number of patients — 120 (66.4 %)); and Group three — patients who were operated simultaneously on both arterial basins (number of patients — 30 (16.5 %)).
Results
The analysis of angiosemiotics of aortic arch branches shows, four types of lesions that influences to choice of surgical tactics:
- only stenoses in carotid and vertebral- subclavian segment;
- stenoses in carotid and occlusion vertebral — subclavian segment;
- occlusion in carotid and stenosis in vertebral- subclavian segment;
- Occlusion in the carotid and vertebral- subclavian segment.
Conclusions
Analysis of the results of our study shows, that the recommendated classification well reflects the degree of severity of aortic arch branches lesions and usably to choice of surgical tactics.
Keywords: multifocal atherosclerosis, concomitant lesions, brain vascular circulation insufficiency.
Introdiction
The notion of multifocal atherosclerosis (MA), which brings together a special category of patients with hemodynamically significant lesions in multiple vascular beds [1; 3; 5]. The defeat of several arterial beds requires to study lesions angiosemiotics and develop new perspectives for choice of tactics.
In the past 10 years, several anatomical classification of lesions of different arterial beds have been proposed, which determined the tactics of further management of patients and selection of adequate treatment [3; 6; 7; 8].
Analysis of the literature shows that the lesions of lower limb arteries studied enough and has the necessary guidance in the choice of tactics intervention [6]. In our opinion, the defeat of the aortic arch branches require further research and development of new methods for choosing the tactics, depending on the types of lesions.
The introduction of modern imaging techniques has allowed to identify the various isolated and combined lesions. The variety of options for the defeat, the different types of course and clinical manifestations of multifocal atherosclerosis necessitate the creation of anatomical classifications, which would serve as a basis for the development of surgical tactics [3; 9; 10]. Classification Trans-Atlantic-Society-Consensus II (TASC II) for aorto-iliac and femoral-popliteal level oflesions are the best tactics to select the appropriate surgical or endovascular intervention [6].
It is shows that, there are anatomical classification of aortic arch branch lesions are not widely used as TASC II recommendations.
Table 1. - Characteristics
Accordingly, the purpose of the study to examine types of lesions of the aortic arch branches and its role in the choice of surgical treatment tactics of patients with concomitant lesions of the aortic arch branches, terminal part of abdominal aorta and lower limb arteries.
Material and methods
Retrospectively analyzed the results of examination and surgical treatment of the 181 patients with combined aortic arch branch and lower limb arteries operated in Vascular Surgery Department from 2000 to 2015years. All patients were divided into three groups: 1 group — 31 (17.1 %) patients whom performed the first step in the reconstruction of the aortic arch branches, 2 group consisted of 120 (66.4 %) patients, which the first stage was completed on reconstruction terminal portion of the abdominal aorta and lower limb arteries and 3 group consisted of 30 (16.5 %) patients operated simultaneously on both arterial basins. The age ofpatients was 51 to 70 years (average 60 ± 1), male patients was 97.2 %.
Various risk factors including age (above 60), sex, smoking, obesity, hypertension, chronic bronchitis, heart failure and stroke detected through the anamnesis were taken into account when assessing the patients. All patients appeared to have nearly five risk factors.
In view to define possible impairments of the arterial beds the patients were exposed to a series of diagnostic tests, such as ultrasound investigation of main arteries, ECG, echocardiography, MRI, MSCT angiography and X-ray contrast angiography. of patients per Group
Group I Group II Group III
(n = 31) (n = 120) (n = 30)
Age 60 ± 1 61 ± 1 60+1
Risk Factors 5.35 ± 0.28 5.24 ± 0.2 4.87 ± 0.27
SMART 326 ± 14 354 ± 9.3 328 ± 16
CLP/ulcers ( %) 38.7 % 6.45 % 71.7 % 23.3 % 51.7 % 10.3 %
Stroke history ( %) 29 % 17.5 % 6.9 %
AIM* history ( %) 22.6 % 28.3 % 20.7 %
Hypertension ( %) 61.3 % 74.1 % 96.2 %
Diabetes mellitus ( %) 16.1 % 18.33 13. 8 %
ABI* (left/right) 0.7 ± 0.06 0.73 ± 0.06 0.51 ± 0.03 0.5 ± 0.027 0.64 ± 0.05 0.56 ± 0.05
Notes: CLI — critical limb ischemia; AIM — acute myocardial infarction; TASC II — trans atlantic Society Consensus II; PAD — peripherial arterial disease; L/R — left/right; ABI — ankle brachial index.
Results. The analysis of angiosemiotics of aortic arch branches lesions in 181 patients we found a pattern that influences the choice of surgical tactics:
- only stenoses in carotid and vertebral- subclavian segment;
- stenoses in carotid and occlusion vertebral-subclavian segment;
- occlusion in carotid and stenosis in vertebral- subclavian segment;
- occlusion in the carotid and vertebral-subclavian segment. In connection with our classification of types of aortic arch
branches lesions were offered (table 2).
Table 2. - Types of aortic arch branches lesions
Type
Image
Description
Type
Image
Description
Only stenosis in carotid and vertebral-subclavian segment
III B
Both side occlusion in carotid and stenosis in vertebral-subclavian segment
II A
Stenoses in carotid and occlusion verte-bral-subclavian segment
IV A
Ipsilateral occlusion in carotid and verte-bral-subclavian segment
II B
Stenoses in carotid and both side occlusion of vertebral-subclavian segment
IV B
Contralaterial occlusion in carotid and vertebral-subclavian segment.
III A
Occlusion in carotid and stenosis in ver-tebral-subclavian segment
IV C
Occlusion in carotid and both side occlusion in vertebral-subclavian segment
I
The study showed that the majority of our patients had type I lesions -65 %. In the I- group patients according to frequency of occurrence greater prevailed I and II types. In other groups, most
patients had I -type lesion of the aortic arch branches (Tab. 3). Depending on the type and severity treatment was determined by the choice of a surgical scope.
Table 3. - Types of aortic arch branches lesions by groups
iype Type TУPe iype
I II III IV
I-gr. (31) 9 (29 %) 10 (32.25 %) 7 (22.6 %) 5 (16.15 %)
II- gr. (120) 87 (72.5 %) 18 (15 %) 13 (10.8 %) 2 (1.7 %)
III- gr. (30) 21 (70 %) 5 (16.67 %) 3 (10 %) 1 (3.33 %)
Total: 181 117 (64.5 %) 33 (18.2 %) 23 (12.7 %) 8 (6.6 %)
Thus patients with type I lesions shows the first stage of end-arterectomy or endovascular intervention on the side of a greater percentage of stenosis. In type II — the first priority is to correct by a greater percentage of stenosis in the carotid. At the III and IV- type lesions in 100 % of cases, the first step is shown at the distal lesion — endarterectomy from external carotid artery (ECA), when in lesions of the proximal segment performed of the different types of bypass surgery on the side of carotid occlusion. The data of visualization techniques of terminal part of abdominal aorta and lower limb arteries were classified according to the recommendations of TASC II aorto — iliac and femoral- popliteal segment.
In 82.3 % of patients showed losions of aorto-iliac segment. In all groups of patients according to frequency of occurrence greater prevailed type A lesions (Table 4). Patients C and D types
Table 4. - Types of aorta ileac
of lesions performed open surgical correction, when A and B types of lesions and the absence of the second unit — endovascular intervention.
Infrainguinal lesions was classified by TASC II recommendations, which stands 4 — type lesions femoro-popliteal segment (tab. 5). The frequency of lesions of the femoro-popliteal segment studied in the number of the lower extremities in the studied group of patients (181). One patient had a history of lower extremity amputation (181 patients and 361 final).
The frequency of femoro-popliteal lesions was 60.4 % (n 218/k s). In II -III- groups of patients according to frequency of occurrence longer prevalent type C, while in Group I — A type of lesion (Table 4). Patients with B, C and D types of lesions performed an open surgical repair.
lesions of TASC II by groups
Lower limb l/l iype А iype В iype С iype D
n % n % n % n %
I-gr. (31) 13 42.0 % 7 22.6 % 3 9.7 % - -
II-gr. (120) 36 30.0 % 23 19.2 % 12 10.0 % 33 27.5 %
III-gr. (30) 12 41.4 % 4 14.0 % 5 17.2 % 1 3.4 %
Total: 181 61 41.0 % 34 22.8 % 20 13.4 % 34 22.8 %
149 (82.3 %)
Table 5. - Types of femoro-popliteal lesions of TASC II by groups
Lower limb № iype А iype В Type С TУPe D
left right left right left right left right
I-gr. 25 7 5 2 3 2 4 1 1
II-gr. 152 23 21 20 18 33 28 3 6
III-gr. 41 5 8 4 2 12 7 1 2
(361) 218 35 34 26 23 47 39 5 9
60.4 % 69 (31.6 %) 49 (22.5 %) 86 (39.5 %) 14 (6.4 %)
Discussion
The first work on options for the development and classification of lesions of multifocal atherosclerosis is found in the works of M. DeBakey. According to him, among 14,000 patients with atherosclerosis in 40 % of cases, the process developed according to the embodiment 1, 30 % as 2 variation. Less than other options of variations 3 (3 % of all patients). At the same time, patients with lesions of options 2 and 3 were younger age, with respect to types of patients from 1, 4, 5 [1].
According to the anatomical and functional significance has 4 arterial beds.
1. The aortic arch branches.
2. Coronary artery.
3. Visceral branches of the abdominal aorta.
4. Terminal Division of the abdominal aorta and the lower extremities arteries.
According to the predominance of clinical lesions for atherosclerosis has 5 options:
1) the aortic arch branches;
2) coronary arteries;
3) visceral branches of the aorta;
4) the terminal abdominal aorta and lower extremities arteries;
5)Ta combination of any of these beds.
L. A. Bokeria et al. (2006) in his classification divided the patients with combined lesions of the aortic arch branches and coronary arteries (CA) to 4 groups depending on the location of the brachiocephalic arteries lesions [3].
B (bifurcation) — defeat of the carotid bifurcation (CB).
S (subclavian) — subclavian- vertebral steal syndrome (SSS).
V (vertebral) — defeat of the vertebral artery.
M (multiple) — multiple lesions of aortic arch branches.
Today widely used type is the classification of coronary lesions ACC/AHA, which takes into account not only the X-ray morphology directly affected segment, but also a host of other factors that affect the outcome of invasive treatment. Currently, this classification is used most widely, not only for the risk assessment of the upcoming endovascular intervention, but also for prognosis of coronary heart disease in general. According to ACC/AHA classification, there are three types of coronary artery stenosis (A, B, C) [5; 9].
In 2000, 14vascular societies ofEurope and North America have adopted recommendations for the defeat of the terminal part of abdominal aorta, iliac and lower extremities arteries (TASC I). Thus allocated aorto-iliac and femoro-popliteal lesion segments, each divided into 4 types (A, B, C, D). With the accumulation of evidence ofusing TASC I, in 2007, a recommendation has been updated and TASC II (Tab. 3-5) has found wide application of practical public health. On the recommendations of TASC II (2007), the defeat of the aorto-iliac segment: the C and D types of treatment choice is surgical, with the A and B types are recommended endovascular interventions [6].
Conclusions
An analysis of the aortic arch branches visualization of results proposed a new classification of types of lesion of aortic arch branches, reflecting the severity of atherosclerotic changes in the arterial beds.
When combined atherosclerotic lesions of the aortic arch branches, the terminal part of the abdominal aorta and the arteries of the lower extremities; tactics and volume of surgical intervention were determined by comparing the types of arterial lesions pools individually for each patient.
Analysis of the results of our study shows this classification well reflects the degree of severity of the branches of the aortic arch, and needs further study and additions to prospective multicenter studies.
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