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III. ХИРУРГИЯ
THE ENDOVASCULAR SURGERY OF RENOVASCULAR HYPERTENSION
Khanchi M., KospanovN.A., OrmanovB.K., DemeuovT.N., Akanov E.K., MatkerimovA.Zh., Zhakubayev M.A., TergeussizovA.S., PangireyevD.D.
National Scientific Center of Surgery named after A.N. Syzganov, Almaty, Kazakhstan. Department of angiosurgery Abstract
From 2000 to May 2010 in Syzganov Scientific Centre of Surgery there were 33 patients in admission, who suffered from RVH and had stenosis-occlusive lesion of other arterial base and who had other diseases.
Endovascular surgical intervention procedures were performed routinely in 33 patients with RVH. Of these, 24 were men, women -9. Bilateral lesion in 4 patients. Repeated endovascular surgical intervention (ESI) performed in 10 cases. Patients with atherosclerotic lesions accounted for the vast majority of the renal arteries (RA) - 23 patients with nonspecific aortoarteritis - 10 of them staged ESI performed in 12 cases.
Single-stage endovascular surgical intervention was performed in 20 patients, 12 patients in stages. In 17 - made transluminal balloon angioplasty (TBA) of RA on the one hand, TBA of RA bilateral - in 4 patients and TBA of brachiocephalic arteries and iliac-femoral segment - at 11.
Thus, in the late postoperative period in patients with primary RVH stenosis and restenosis PA when we performed endovascular surgical intervention positive clinical results observed in 82% of cases. There were no deaths in the studied group of patients. After the angioplasty in patients with atherosclerosis there was a significant decrease (p<0.05) of the average blood pressure: systolic 205 + 4 mm Hg 135 + 2.2, and diastolic from 110 + 1.3 mm Hg 90+1.2 mm Hg in patients with aortoarteritis average blood pressure was significantly decreased (p <0.05): systolic 210 + 8.2 mm Hg + 5.7 to 146 mm Hg and diastolic from 115 + 5.3 mm Hg 90y1.6 mm Hg. Statistical analysis of indicators of blood pressure before and after endovascular surgical treatment gave a good hemodynamic effects in 27 patients.
Реноваскулярльщ гипертензияньщ эндоваскулярлыкхирургиясы
Ханчи М., Коспанов H.A., Орманов Б.К., ДемеуовТ.Н., Аканов Е.К., Маткер1мов А.Ж., Жакубаев М.А., ТергеуЫзов A.C., Пангиреев Д.Д.
А.Н. Сызганов атындагы Улттык; гылыми хирургия орталыгы, Алматы, К,азак;стан. К,ан тамырларды емдеу большей. Ацдатпа
Сонымен, 82% окигада эндоваскулярлык, хирургиялык араласулар, ягни оталар жасаган кезде, РВГ ауруынын алгашк,ы сте-нозымен жэне ПА рестенозымен ота жасалганнан кешн мерзш узарган ауруларда ом клиникалык, нэтижелер1 орын алган.
Аурулардыц зерттеу тобында олшжтм тургысынан ок,игалар болмаган. Атеросклерозына шалдыщан ангиопластика-дан кетнп пациенттер саны айтарльщтай азайды: орта есппен алгандагы артериялдык, кан кысымы сынап баганасы бойынша систолиялык 205 + 4 мм 135 + 2,2 дейт, ал аортоартеритке шалдыщан аурулар арасында диастолиялык, НО + 1,3 мм бастап 90 + 1,2 мм дейт, систолиялык, 210 + 8,2 бастап 146 + 5,7 мм детн жэне дистолиялык 115 + 5,3 мм бастап 90 у 1,6 мм детн (р<0,05) айтарлыцай темендед1.
Эндоваскулярлык, хирургиялык емдеуте дешн жэне содан кетнп артериялык, кан к,ысымыныц статистикалык, талдауынын KopceTKiurrepi бойынша 27 пациентке эсерт типздi.
UDC 616-089
ABOUT THE AUTHORS: Nursultan A. Kospanov - head of the department of angiosurgery, can. med., a high level certificate physician, e-mail: Kospanov. nursultan@gmail.com; Khanchi M. - surgeon of the department of angiosurgery, can. med., a high level certificate physician,
e-mail: khanchi.mead@yahoo.com
Key words:
multifocal stenotic lesions of various etiologies of arterial vessels (atherosclerosis, aortoarteritis), endovascular methods.
АВТОРЛАРТУРАЛЫ:
Коспанов Нурсултан Айдарханулы - А.Н. Сызганов атын. YFXO к,ан-тамырлар хирургия-сы бел1мшесМц мецгерушШ, m.f.k., жогзрры санатты Mepirep, e-mail: Kospanov.nursultan@gmail.com; Ханчи М. - А.Н. Сызранов атын. YFXO к,ан-гамырлар хирургиясы бел1мшес1н1цMepirepi, M.f.к., жогзрры санатты Mepirep e-mail: khanchi.mead@yahoo.com
Туйш сездер
артериялык, кан-тамырлардыц турл1 этиолотиясынын мультифокалды стенотикалык закыщануы (атеросклероз, аортоартерит), эндоваскулярлык, эдютер.
Эндоваскулярная хирургия реноваскулярной гипертензии
Ханчи М., Коспанов H.A., Орманов Б.К., Демеуов Т.Н., Аканов Е.К., Маткеримов А.Ж., Жакубаев М.А., Тергеусизов A.C., Пангиреев Д.Д.
Национальный научный центр хирургии им. А.Н. Сызганова, Алматы, Казахстан. Отделение ангиохирургии. Аннотация
С 2000 года по май 2010 в научном центре хирургии им. Сызганова было 33 пациентов на приеме, которые страдали отре-новаскулярой гипертензией (РВГ) и были стеноз-окклюзионные поражения другой артериальной базы и которые имели другие заболевания.
Эндоваскулярные хирургические процедуры вмешательства проводились регулярно у 33 пациентов с РВГ. Из них 24 были мужчины, женщин - 9. Двустороннее поражение у 4 пациентов. Повторное эндоваскулярное хирургическое вмешательство (ЭХВ) осуществлялось в 10 случаях. Пациенты с атеросклеротическим поражением приходились для подавляющего большинства почечных артерий (ПА) - 23 пациентов с неспецифическим аортоартеритом - 10 из них выполнено стадийное ЭХВ в 12 случаях.
Одностадийное эндоваскулярное хирургическое вмешательство было выполнено у 20 пациентов, 12 больных по стадийно. У 17 - транслюминальная баллонная ангиопластика (ТБА) ПА, с одной стороны, ТБА ПА двустороннего - у 4 больных и ТБА бра-хиоцефальных артерий и подвздошного бедренного сегмента - у 11.
Таким образом, в отдаленном послеоперационном периоде у больных с первичным стенозом РВГ и рестенозом ПА были положительные клинические результаты, когда мы выполняли эндоваскулярные хирургические вмешательства в 82% случаев. Ни одного случая смерти в исследуемой группе больных не наблюдалось. После ангиопластики у пациентов с атеросклерозом было значительное уменьшение (р <0,05) в среднем артериального давления: систолическое с 205 + 4 мм рт.ст. до 135 + 2,2, а диастолическое от 110 + 1,3 мм рт.ст. до 90 + 1,2 мм рт.ст. у пациентов с аортоартеритом среднее кровяное давление значительно уменьшилось (р <0,05): систолическое 210 + 8,2 мм рт.ст. до 146 + 5,7 мм рт.ст., и диастолическое от 115 + 5,3 мм рт.ст. до 90 у 1,6 мм рт. Статистический анализ показателей артериального давления до и после эндоваскулярной хирургического лечения дал хорошие гемодинамические эффекты у 27 пациентов.
ОБ АВТОРАХ:
Коспанов Нурсултан Айдарха-
нович - заведующий отделением ангиохирургии ННЦХ им. Сызганова, к.м.н., врач высшей категории, хирург, e-mail: Kospanov.nursultan@ gmail.com;
Ханчи М. - врач-хирург отделения ангиохирургии ННЦХ им. Сызганова, к.м.н., врач высшей категории, e-mail: khanchi.mead@yahoo.com
Ключевые слова:
мультифокальные стенотиче-ские поражения различной этиологии артериальных сосудов (атеросклероз, аортоартерит), эндоваскулярные методы.
Table 1.
Distribution of patients according to the etiology of renovascular hypertension
The problem of surgical treatment of renovascular hypertension (RVH) whitening at which a persistent increase in blood pressure due to lesions (stenosis, occlusion) of the renal arteries or their branches without a primary lesion of renal tissue and urinary tract, remains relevant today. [1, 2, 3]
Currently, arterial hypertension (AH) is ranked first in the morbidity structure of the population and is one of the leading causes of temporary or permanent disability, premature disability and death. That is why the problem of the treatment is of great socio-economic importance. [5]
Notable among patients with RVH take patients with multifocal stenotic lesions of various etiologies of arterial vessels (atherosclerosis, aortoarteritis). [5] The aim of the study - to show the effectiveness of a comprehensive approach in the choice of surgical approach in the treatment of patients with RVH and multifocal vascular lesions.
Endovascular surgical intervention procedures were performed routinely in 33 patients with RVH. Of these, 24 were men, women - 9. Bilateral lesion in 4 patients. Repeated endovascular surgical intervention (ESI) performed in 10 cases. Patients with atherosclerotic lesions accounted for the vast majority of the renal arteries (RA) - 23 patients with nonspecific aortoarteritis - 10 of them staged ESI performed in 12 cases. (Table 1)
Indications for endovascular surgical considered resistant hypertension in patients with an-giographically established hemodynamically significant narrowing of the arteries by more than 50% stenosis and restenosis RA.
Contraindications include acute respiratory infections, severe heart and kidney, liver failure, myocardial infarction or cerebral stroke in the previous two months, the active phase flow aortoarteritis nonspecific, and the presence of abdominal aortic aneurysms.
In patients with a combination of RVH with many vascular lesions considered optimal tactics in which finally solved the question of the scope and phasing of the endovascular treatment. At the same time it was felt the need to take into account the subjective and objective indicators of well-being and the general condition of the patients to make appropriate corrections in the program endovascular surgical. Treat technical inaccuracies or adverse reactions
when endovascular surgical as factors limiting the scope ofthe operation.
When smooth flow endovascular surgical task was to RVH patients with multivessel intervention simultaneously produce 2-3 arteries.
In the event of major changes and health status of patients, violations of the ECG, adverse events and technical difficulties, to suspend rational thought surgery, undertake the necessary remedial measures and, under appropriate conditions, to complete the endovascular surgical, limiting dilatation single vessel stenosis.
Single-stage endovascular surgical were performed in 20 patients, 12 patients in stages. In 17 - made transluminal balloon angioplasty (TBA) RA on the one hand, TBA of RA bilateral - in 4 patients and TBA brachiocephalic arteries and iliac-femoral segment - at 11.
Endovascular prosthesis, renal artery stenting
Stenting of RA produced in 5 patients (1 male and 4 female) with stents SCHATZ ballon - expandable Gohnson-Gohnso, self-expanding nitinol and Kavteladze. For fixing the endovascular prostheses there was used attachment system comprising a radially expandable balloon stent. Endovascular prosthesis installed femoral arterial access using catheters with means for the introduction of endovascular prosthesis with stents.
After dilation and control angiography injected through a wire to the RA in the postoperative period was performed appointment within 7 days of low molecular weight dextran or Vazoprostan, anticoagulants and antiplatelet agents.
The method of endovascular prosthesis RA is the most effective in patients with severe comorbidities, the presence of contraindications to high-risk operations as well as the method of choice in cases of lesion artery only functioning kidney.
Two-stage endovascular surgical intervention
We observed surgical treatment of 12 patients in whom angiographic stenosis set the other two main arteries, that is, there was three-vessel damage. These patients during the first stage of surgery were performed TBA of renal artery, the second
Etiological factors RVH number of patients Men Women
№ % № % № %
Atherosclerosis 23 70% 23 70% 0 0
Aortoarteritis 10 30% 1 3% 9 27%
Total 33 100% 24 73% 9 27%
phase - TBA of other main arteries. With a significant violation of hemodynamics brachiocephalic arteries in the first stage produced TBA on the carotid arteries. 8 patients in the first stage were carried out TBA of brachiocephalic artery, the second stage configured TBA of renal artery in 4 patients interference produced in the reverse order.
One patient with advanced aortoarteritis process had hemodynamically significant stenosis of 6 vessels: both renal, left subclavian and vertebral, right carotid arteries. It was carried out a two-stage treatment. The first step made TBA of subclavian, vertebral and both sides of the carotid arteries with good effect, the second stage, after 3 months, the two-stage dilation ofthe renal arteries.
This observation demonstrates the extensive technical capabilities in atherosclerotic occlusive endovascular surgical multivessel disease and good clinical outcomes, tracked over an extended period in patients with combined forms.
Analysis of the results endovascular surgical intervention
Our experience with TBA, RA stenosis in all cases was due to atherosclerotic lesions and aortoarteritis, after the operation was hypotensive effect. An analysis of clinical results in patients with RVH conducted with the systolic and diastolic blood pressure without antihypertensive therapy, as well as the general condition and well-being of the patient. Indicators of blood pressure in patients undergoing major changes VRG during the first hours after endovascular surgery were subjected to a comparative analysis of indicators of blood pressure before and after endovascular surgical in 33 patients, 20 of them with atherosclerotic lesions, with aortoarteritis - 10 patients. Complications after surgery has 1 patient (RA occlusion). Postoperatively, 10 patients had been diagnosed and confirmed by angiographic restenosis caused over the next 1 to 6 months after endovascular surgical intervention.
In all cases, the RA restenosis in patients with relapsed accompanied by arterial hypertension with characteristic clinical picture, in 4 patients with atherosclerotic lesions in 6 - with , aortoarteritis. All patients were performed repeated endovascular surgical intervention to eliminate stenosis and restenosis RA.
Analysis of long-term clinical results of treatment of 33 patients with combined RVH (22.6% of all treated) who underwent dilation of stenotic and restenotic arteries showed that the positive clinical results of endovascular surgical intervention were obtained in 27 patients. Highest endovascular surgical results were obtained in patients with atherosclerotic.
V
Picture 1.
Angiogram. Patient K. 60 years. Stenosis of both renal arteries. Abdominal aortic aneurysm with stenosis of the right renal artery
Picture 2.4.
Angiogram. Control aortography patient Sh 55 years after renal artery stenting Right
Low efficiency rate of endovascular surgical
intervention was installed in 6 patients with restenosis with nonspecific aortoarteritis and diffuse RA stenosis.
The greatest number of good and satisfactory results in the near term after endovascular surgical intervention was observed in 27 patients with multifocal atherosclerotic lesions and the lowest - in 6 patients with aortoarteritis.
Overall, of the 33 patients RVH surveyed after endovascular surgical positive clinical results were characterized by normal levels of blood pressure, or a significant and sustainable reduction in the degree of blood pressure were obtained in 27 (82%) patients. Unsatisfactory results were 6(18%) cases.
Due to the fact that currently there is no reliable method of predicting outcomes REHV in these patients, we believe that it has been shown to endovascular treatment. The arguments in favor of such a decision was made in the results of our observations, when the number of observations in patients
with concomitant VRG pyelonephritis after the effective technically TBA, RA, there is a good or satisfactory clinical outcome. Moreover, the literature suggests that renal neovascularization leads to improved secretion capacity of the kidneys in patients not only with normal or mildly elevated creatinine levels, but also in patients with severe azotemia or dialysis with RVH.
Thus, in the late postoperative period in patients with primary VRH stenosis and restenosis PA positive clinical results when we performed endovascular surgical intervention observed in 82% of
cases. There were no deaths in the studied group of patients. After the angioplasty in patients with atherosclerosis significant decrease (p <0.05), the average blood pressure: systolic 205 + 4 mm Hg 135 + 2.2, and diastolic from 110 + 1.3 mm Hg 90 + 1.2 mm Hg in patients with aortoarteritis average blood pressure was significantly decreased (p <0.05): systolic 210 + 8.2 mm Hg + 5.7 to 146 mm Hg and diastolic from 115 + 5.3 mm Hg 90 y 1.6 mmHg Statistical analysis of indicators of blood pressure before and after endovascular surgical treatment gave a good hemodynamic effects in 27 patients.
References
1. Bokeria L.A. et al. Endovascular treatment of patients with multifocal atherosclerosis. - Annals of Surgery. 2002, - №1, p. 11-17.
2. Petrovsky B.V. et al. 40 years of experience in reconstructive surgery at renovascular hypertension. - Angiology and Vascular Surgery. -2003, №9, pp 8-12
3. Pokrovsky A.V. Clinical Angiology Moscow -2004.
4. Belichenko I.A., Kungurtsev V.V., Kukharchuk
V.V. Selecting operations for surgical tactics in patients with renovascular hypertension // -M. -1981. -p.131.
5. Bush R. at al. Endovascular revascularization of renal artery stenos is: Technical and clinical // Vase. surg. -2001.№ 33 (5). -P.1041-1049.
6. Akchurin P .With, et al. Surgical tactics in patients with renovascular hypertension // Actual problems ofAngiology. -M. -1989. -p. 84-85.
